Veterans Affairs National Center for Patient Safety Patient Safety Fellowship, White River Junction VA Medical Center, White River Junction, VT 05009, USA.
Gen Hosp Psychiatry. 2012 May-Jun;34(3):304-11. doi: 10.1016/j.genhosppsych.2011.12.007. Epub 2012 Jan 27.
The objective was to identify how falls on psychiatric units occur, the underlying root causes and effective action plans to reduce falls and injuries.
A search of the Veterans Health Administration National Center for Patient Safety database was conducted to identify root cause analysis (RCA) reviews where a fall was sustained by a patient on a psychiatric unit. Seventy-five RCAs from January 2000 to March 2010 were included.
One hundred and thirty-eight actions were identified from the RCA reports. The most common activities the individual was engaged in during a fall included getting up from a bed, chair or wheelchair (21.3%); walking/running (10.7%); bathroom related (9.9%) or behavior related (9.9%). The most common root causes were environmental hazards (11.2%), poor communication of fall risk (8.9%), lack of suitable equipment (8.9%) and need for improvement of the current system for falls assessment (8.9%). Staff education (19.9%), development of tools to improve falls documentation (17.0%) and providing falls prevention equipment (14.2%) were the most frequent actions taken.
The results describe the location, activity and root causes surrounding falls that occur in psychiatric units resulting in injury, and provide some suggestions on how to implement a successful action plan.
旨在确定精神科病房跌倒的发生方式、根本原因，并制定有效计划以减少跌倒和伤害。
检索退伍军人健康管理局国家患者安全中心数据库，以确定因跌倒而接受患者的根本原因分析 (RCA) 审查。纳入了 2000 年 1 月至 2010 年 3 月的 75 项 RCA。
从 RCA 报告中确定了 138 项行动。个人跌倒时最常见的活动包括从床、椅子或轮椅上起来（21.3%）；行走/跑步（10.7%）；与浴室相关（9.9%）或与行为相关（9.9%）。最常见的根本原因包括环境危害（11.2%）、跌倒风险沟通不畅（8.9%）、缺乏合适的设备（8.9%）以及需要改进当前跌倒评估系统（8.9%）。最常见的措施包括员工教育（19.9%）、开发改进跌倒记录的工具（17.0%）和提供跌倒预防设备（14.2%）。
研究结果描述了导致受伤的精神科病房跌倒的地点、活动和根本原因，并就如何实施成功的行动计划提出了一些建议。
