Soncrant Christina, Neily Julia, Bulat Tatjana, Mills Peter D
Veterans Health Administration, National Center for Patient Safety, White River Junction, Vermont (Mss Soncrant and Neily and Dr Mills); Veterans Health Administration, VISN 8 Patient Safety Center of Inquiry, Veterans Affairs Medical Center, Tampa, Florida (Dr Bulat); University of South Florida Morsani College of Medicine, Tampa (Dr Bulat); and The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (Dr Mills).
J Nurs Care Qual. 2020 Jan/Mar;35(1):77-82. doi: 10.1097/NCQ.0000000000000408.
Injurious falls continue to challenge health care. Causes of serious falls from the largest health care system in the United States can direct future prevention efforts.
This article analyzes injurious falls in the Veterans Health Administration and provides generalizable recommended actions to prevent future events.
We categorized root cause analysis (RCA) reports and coded injury type, fall type, location, and root causes. We describe interventions during the fall and provide resources for future prevention.
There were 154 reported fall RCAs during this time. Most (83%, n = 128) resulted in major injury: hip fractures (43%, n = 66), other fractures (25%, n = 38), and head injury (16%, n = 24). Most falls were unwitnessed (75%, n = 116).
Patients who fell were not wearing hip or head protection. Most falls were unwitnessed, and none were on 1:1 observation. Such interventions may help prevent future injurious falls.
跌倒致伤仍是医疗保健面临的挑战。美国最大的医疗保健系统中严重跌倒的原因可为未来的预防工作提供指导。
本文分析了退伍军人健康管理局中的跌倒致伤情况，并提供可推广的预防未来事件的建议措施。
我们对根本原因分析（RCA）报告进行分类，并对损伤类型、跌倒类型、地点和根本原因进行编码。我们描述了跌倒时的干预措施，并为未来的预防提供资源。
在此期间共报告了154例跌倒的RCA。大多数（83%，n = 128）导致重伤：髋部骨折（43%，n = 66）、其他骨折（25%，n = 38）和头部损伤（16%，n = 24）。大多数跌倒未被目击（75%，n = 116）。
跌倒的患者未佩戴髋部或头部保护装置。大多数跌倒未被目击，且均未进行一对一观察。此类干预措施可能有助于预防未来的跌倒致伤事件。
