ROOT CAUSE ANALYSIS AND FREQUENCY OF FALLINGS IN A UNIVERSITY HOSPITAL

Objective: this study has been made as a descriptive evaluation for the purpose of understands the root cause analyses and frequency of fallings in a university hospital. methods: no sampling was made in the study. the study population included patients falling down in all clinics of a university hospital between march-august 2010 (n=61). the dates were collated by “falling inpatient notification form” developed by researchers and consisted of six parts. eindhoven classification model and number, percent distribution, mean and kappa cohesion analysis was used in analyses of the data. results and conclusion: 33.4% of the patients are between 61-75 ages and the mean is 62.2 (ss=1.55). over half of the patients (52.5%) were female, and a small proportion (19.7%) had a previous history of falling accident for one or more times. 32.8% of the patients were fallen in the first three days. 36.3% of the fallings were seen between 04-08 a.m. 54.1% of the fallings happened in the patient room. in 32.78% of the fallings resulted in injury. the mean falling ratio of the hospital was %0.33 and neurology clinic had the highest ratio with %1.54. the most common causes of the fallings were patient’s carelessness (32.8%), physical status of the patient (32.8%), lack of patient relatives (22%). causal trees were formed for each falling. totally 241 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. in light with the obtained results, it could be suggested to take right, convenient and peculiar precautions by evaluating the reasons of falling accidents through risk evaluation scale in patients falling or with high risk of falling. in this context, it is recommended to the falls and risk assessment committees should be established to monitoring patient falls at the institutional level, evaluating the results of the falls and improving the prevention.