Root Cause Analysis of Reported Patient Falls in ORs in the Veterans Health Administration

Abstract

This quality improvement project describes 22 OR patient falls reported in the Veterans Health Administration between January 2010 and February 2016. Most (n = 15; 68%) involved patient falls from the OR bed. Other patient falls (n = 6; 27%) occurred when the patient was transferred to or from the OR bed, and one fall (5%) occurred at another time. Root causes of the falls included tilting of the OR bed, issues with safety restraints, malfunctioning OR bed or gurney locks, inadequate patient sedation, and poor communication among team members. One fall (5%) resulted in a major injury, four falls (18%) resulted in minor injuries, six falls resulted in no injury, and 11 falls (50%) had no reported outcome. Falls in the OR, although rare, can be injurious. We drafted recommendations based on the root causes that include specific guidance on communication, teamwork, best practices, restraints and equipment, and training.

Guidelines in Practice: Positioning the Patient

“…Use of a decision‐support tool during preoperative assessments and planning may help team members identify at‐risk patients and possible interventions to decrease their risk 5 . The team should discuss the planned positioning interventions during the preoperative briefing, 1 which may promote team member awareness of the patient's specific needs and the required positioning equipment to maintain patient safety 6 . Perioperative team members should evaluate the effectiveness of the positioning interventions during the postoperative debriefing to identify patterns in outcomes associated with the interventions 1…”

AORN Position Statement on Patient Safety

“…When adverse events and near misses occur, these should be viewed as opportunities for learning and improvement instead of grounds for punishment, 2,23,31 although this does not eliminate the need for accountability 2 . Elements of a perioperative patient safety culture include effective leadership, 2 accountability (ie, taking responsibility for one’s actions), 2 transparency (ie, openly sharing information), 2 psychological safety (ie, an environment in which people feel comfortable speaking up), 2 teamwork and communication (eg, respect), 2,32 reliability (ie, using the best evidence and minimizing variation to eliminate error [developing a high‐reliability team ]), 2 improvement and measurement (ie, developing and testing system improvements and measuring effects and outcomes over time), 2 continuous learning (eg, conducting root cause analyses, examining collected data to identify what is working or failing), 2,32,33 advocacy (ie, advocacy for patients and to address social determinants of health), 34 and an effective event reporting policy and procedure that includes reporting near miss safety events 2,31,35 …”

“…• continuous learning (eg, conducting root cause analyses, examining collected data to identify what is working or failing), 2,32,33 • advocacy (ie, advocacy for patients and to address social determinants of health), 34 and…”

Avaliação da segurança do doente no bloco operatório: perceção dos enfermeiros

“…Available evidence shows that most falls in the OR involve obese patients under general anesthesia with extreme surgical positioning. Most of these falls occur upon awakening from anesthesia, during surgery, and patient transfer to the bed (Prielipp et al, 2017;Soncrant et al, 2018). According to Prielipp et al (2017), falls are caused by factors related to the patient (obesity, age, sedation, altered consciousness, and agitation), the staff (distraction, team coordination problems, the assumption that other staff members are monitoring the patient, and production pressures), and the operating table (equipment failures, improper use, lack of knowledge, absence or incorrect application of restraints, and extreme tilt positioning).…”