Root Cause Analysis: Root Patient Factors

On the other side of the equation, patient lack of motivation for self-care, preoccupation with pressure ulcer risk and treatment, inaccurate information about treatments and causation, lack

During hospitalizations, falls are amongst the highest preventable consistent adverse events. Preventing such undesirable events, enhances patient overall experience, as well as increased trust in the health care professional team (Fragata, 2011). The importance of fall prevention lies with the many serious unfavorable health outcomes it can pose on the patient. Falls have the potential increase length of hospital stay, limit mobility, independence, but can ultimately lead to health deterioration, including death. Worldwide, falls are the second leading cause of accidental death. In addition to the life-threatening health and safety risks falls have to the patient, it also as a financial impact,

| WEAKENSSES: * financial support and available funding * reputation of services as such mistreating patients * lack of access to technology in these areas * management or staff availability * lower income areas * undifferentiated service lines

Everyone should have the opportunity to achieve a healthy life and have comprehensive health care services available to them. To achieve this healthy life, people need to have access to the health care system and to a health care provider with whom they can develop a trusting relationship. However, existing barriers to attaining health care services often lead to disparities which in turn lead to differences in life expectancy, health status and a higher prevalence of certain chronic diseases (HealthyPeople.gov, 2012).

Problem: Patient falls have long been a common and serious problem in hospitals across the nation, causing

There are difficulties and challenges on how to facilitate and what tools to use to resolve the determinants of health such as

Current barriers include: a mistrust of the medical community, not having a primary physician, not following through on regular medical appointments, and lack of a support system; all of these having the potential to cause

This is true for insured, uninsured, and under-insured Americans. These problems are exacerbated by a lack of coordination of care for patients with chronic diseases. The underlying

Root cause analysis process will utilize a systematic step-by-step approach to help identify all causative factors leading to this sentinel event. The main purpose of the Root Cause Analysis is to understand how the event happened, why did it happen, and what can be done to prevent an event from happening again. The first step, collect all necessary data associated with this event such as: current policy and procedures, incident report, Mr. B’s health history, environmental flowcharts, dispensed medications, equipment and staffing factors relevant to the event. The process of identifying causative factors can begin once all the data is collected. The goal, of a Root Cause Analysis, is to identify interventions to prevent an event from reoccurring.

risk factors for disease and injury, socioeconomic status, access to health care use due to

Fall risk assessments tools, which help to identify those patients at risk of falling, play a vital role in reducing the number of falls. The basis for this assessment is that if patients at high fall risk can be

Lack of doctors is only one facet to this multifaceted problem. Accessibility in terms of having the financial resources to obtain care is another. “Individuals in lower social status groups have the highest rates

Risk factors for falls are categorized by intrinsic or extrinsic (Tzeng, & Yin, 2009). According to Tzeng and Yin (2008), intrinsic factors, referring to the patient themselves, are related to their health status and possibly associated with age-related changes: previous falls, reduced vision, unsteady gait, musculoskeletal system deficits, mental status deficits, acute illness, and chronic illness. Extrinsic factors are involved in the patient’s environment, including medications, lack of support equipment, furniture, bathroom designs, small patient rooms, poor lighting, and improper use of and inadequate assistive devices. Tzeng & Yin (2008; 2009) focused on the extrinsic risk factors for the basis of their studies.

Qualitative data analysis was obtained in this study in which eight major themes were revealed. The overall perception includes past falls, fall risks, and fear of fall-related injuries. (Shuman, 2016). Overall, the initial perception of the patients was they did not receive fall prevention information. As the interview continues the participants were able to give examples of fall preventions given to them by the healthcare providers’. The data analysis supports the conclusion that healthcare providers need provide clarity to patients and family member in order to prevent falls.

Access to healthcare is a factor of great importance that needs to be addressed by any healthcare system. Issues such as the