A large, multi-facility health system was concerned about an increase in falls in their acute care facilities.
Using ECRI Institute PSO’s proprietary review process, our patient safety analysts evaluated the system's documentation of root cause analyses (RCAs) related to fall events, which provided the following results:
- A summary of commonalities across fall events such as activity prior to fall, age of patient, time of fall, and injury
- An evaluation of the effectiveness of the action recommendations from the RCAs based on factors such as scope, timeliness, and risk reduction
- Recommendations to improve the effectiveness of the RCA actions
The health system shared the results of this review across all facilities in order to educate RCA leaders about opportunities to increase awareness about the benefits of RCAs. Finding common events across all facilities can help identify system-wide themes and target them for improvement. This health system made improvements to their RCA process, collaborating with ECRI Institute PSO to evaluate those improvements.
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