A Longitudinal Study of a Multifaceted Intervention to Reduce Newborn Falls While Preserving Rooming-In on a Mother-Baby Unit

Root cause analysis and strategies for reducing falls among inpatients in healthcare facilities: A narrative review

“…Studies were conducted in the United States 6 and Saudi Arabia, 1 published between 2008 and 2022. Four studies were conducted in a general hospital (inpatient units), 29 , 31 , 33 , 34 1 study in a children's hospital (mother and baby unit), 30 1 study in an acute care hospital (inpatient behavioral unit), 23 and 1 study in a level one trauma center (emergency department). 32 All studies were interventional and used the RCA method to identify the causes of inpatients' falls.…”

“… 32 All studies were interventional and used the RCA method to identify the causes of inpatients' falls. 23 , 29 , 30 , 31 , 32 , 33 , 34 Most studies had established interdisciplinary quality improvement teams and committees to identify causes of falls, 23 , 29 , 30 , 31 , 33 , 34 and only one study had revised an existing risk assessment tool. 32 Further details of RCA participants and interventional period are described in Table 2 .…”

“…Causes such as medication/sedation, inappropriate footwear, unexpected movement, gait and balance limitations, patients under the influence of alcohol, and cognitive impairments (confusion, disorientation, memory deficits, and dizziness) were identified with higher frequency as contributing patient‐related factors to falls. 23 , 29 , 30 , 32 , 34 Various environmental factors have been identified in studies as contributors to falls. These include issues with toilets, tubs, and showers, equipment that poses tripping hazards, a noisy environment, wet floors, cold room temperature, bed/side rails, call lights not being used, crowded rooms, flooring problems, and poor lighting.…”

“…These include issues with toilets, tubs, and showers, equipment that poses tripping hazards, a noisy environment, wet floors, cold room temperature, bed/side rails, call lights not being used, crowded rooms, flooring problems, and poor lighting. 23 , 29 , 30 , 34 The study identified organizational and process factors contributing to falls, including the absence of hourly rounding, improper use of bed alarms, tab alarms, or call bells, an incomplete fall risk assessment tool, and the lack of routine falls risk assessments at admission. 30 , 31 , 32 , 34 Staff and communication factors can contribute to falls.…”

“… 23 , 29 , 30 , 34 The study identified organizational and process factors contributing to falls, including the absence of hourly rounding, improper use of bed alarms, tab alarms, or call bells, an incomplete fall risk assessment tool, and the lack of routine falls risk assessments at admission. 30 , 31 , 32 , 34 Staff and communication factors can contribute to falls. Some causes related to these factors include a lack of team communication regarding fall risk assessment, inadequate staff accountability to follow fall prevention protocols, and inadequate safety awareness by staff.…”