Root cause analysis and frequency of fallings at the university hospital

Purpose: This study has been made as a descriptive evaluation for the purpose of understand the root cause analysıs and frequency of fallings in a university hospital.Methods: Cases were taken from 29 clinics in a university hospital between March - Agust 2010 (N=61). The dates were collated by ?Falling Inpatient Notification Form? consisted of 6 parts. The datas were collected by the nurses by asking the patient and copying from the patient files. Eindhoven Classification Model and number, percent and aritmetic means were used in anlayses of the data.Findings and Results: 33.4% of the patients are between 61-75 ages and the mean is 62.2 (SS=1.55). 52.5% of the cases are women and 19.7% were fallen once or more before. 32.8% of the patients were fallen in the first three days. 36.3% of the fallings were seen between 04-08 a.m. and 52.45% happened during the night shift of the nurses. 54.1% of the fallings happened in the patient room and 19.7% of the patients were found on the ground. 22.95% of the patients were found to have one or more medical diagnosis. Precautions were not satisfactory in moot cases. In 21.3% of the fallen patiens no risk analysis were done and 32.78% of the fallings resulted in injury. The mean falling ratio of the hospital was 0.33 and neurologyc clinic had the highest ratio with 1.54. The most commen causes of the fallings were patients carelessness (32.8%), physical status of the patient (32.8%), unalibility of occompanientment (22%). Causal trees were formed for each falling . Totally 224 root cause was defined and 3-4 root cause were found for each falling. The causal trees were found to be patient related factors (45%), rule-based behaviors errors (23%) technical (15.8%) and organizational (8%) errors.Key words: Sentinel events, fall of patient, root cause analysis, PRISMA