Root-Cause Analysis and Safety Improvement Plan
Understanding What Happened
1. What happened?: Begin by An 82-year-old male with pneumonia, hypertension, and mild cognitive impairment was
understanding the sequence of admitted to the medical-surgical unit. Despite being at high risk for falls (Morse Fall Scale = 55),
events leading up to the sentinel the patient attempted to ambulate unassisted to the bathroom at 2:15 a.m. on the third night
event. Gather detailed information of admission. His bed alarm was not functioning properly, and it failed to alert staff. The night
about the incident, including nurse and the assistant were occupied with another patient in respiratory distress, and the
the timeline, people involved, charge nurse was at the station. Due to the overwhelming nurse-to-patient ratio (1:8), hourly
and context. rounding was delayed, and the patient was left alone. Approximately five minutes later, a nurse
o Who did the found him on the floor next to the bathroom. On examination, there was a shortened,
problem/event affect, and externally rotated right leg, consistent with a hip fracture. Radiology confirmed a fracture of the
how? right femoral neck that required surgery.
Whom did the problem/event affect, and in what manner?
The patient had a fracture of the hip that required surgery, which caused him severe pain,
immobility, emotional distress, and a prolonged hospital stay of 10 extra days. His risks of
developing complications such as infection, delirium, and pneumonia were significantly
heightened. For the family, there was a loss of trust in the hospital's safety procedures, with
meetings with risk management being undertaken. The healthcare team experienced moral
distress, guilt, and workload created by incident reporting, which negatively impacted staff
morale and staff trust in fall-prevention systems. At an organizational level, the event caused
added expense from surgery and extended care, was classified as a sentinel event, and exposed
the hospital to lawsuits and loss of reputation.
2. Why did it happen?: The fall was caused by numerous human, system, and cultural problems. Handoff
o Human Factors: Investigate communication failure meant that prior unassisted ambulation attempts were not highlighted,
whether communication and the patient was not properly educated about his fall risk. Delayed rounding was the result
breakdowns, staff fatigue, of staff exhaustion from excessive patient loads (1:8 ratios) and understaffing. Training gaps and
or lack of improper bed alarm use heightened risk. System issues included workflow strain,
training contributed. malfunctioning equipment, inadequate lighting, and environmental hazards. Inadequate safety
o System Factors: culture, lack of proactive staffing, and alarm fatigue lowered adherence. The patient's cultural
1
, Examine workflow expectation of independence also deterred him from summoning assistance.
processes, equipment
failures,
and environmental factors.
o Organizational Culture:
Assess if there are cultural
issues, lack of safety
culture, or inadequate
leadership support.
o Society/Culture: What role
might cultural
assumptions or
backgrounds play?
3. Was there a deviation from Hospital protocol requires aggressive fall-prevention measures in high-risk patients (Morse ≥
protocols or standards?: 45), including: activated bed/chair alarms, call bells within reach with patient education,
o Procedures and Policies: prominent signs, two-hour scheduled toileting, hourly rounding, and repeat fall risk evaluation
Determine if at each shift handoff. In this case, there were several deviations. The bed alarm was broken and
established protocols were hadn't been inspected in over six months; a pre-shift functionality check by staff was also
followed or if there were neglected. The patient did have a call bell but lacked reinforcement on its use and was opposed
deviations. to "bothering the nurses." Scheduled two-hour toileting was overlooked, with more than 3.5
o Were there any steps that hours between checks. Purposeful rounding was delayed because of workload and lacked
were not taken or did not documentation at intended intervals. While fall-risk signage was present, other cues like non-
happen as intended? slip socks and reminders were not. Re-assessment at handoff was omitted, and the night nurse
o Documentation: failed to re-assess the Morse score.
Review medical Other deviations included failure to escalate staffing needs during a respiratory crisis, no re-
records, nursing notes, and education following prior unassisted ambulation attempts, and delayed maintenance reporting
other relevant of alarm issues. Although post-fall protocol (evaluation, imaging, reporting) was followed,
documentation. preventive interventions were implemented variably. Overall, system deficiencies and policy
deviations significantly contributed to the adverse event.
2
, Documentation (what the records show and gaps identified)
Nursing documentation was assessed and found to be severely lacking. The electronic flowsheet
did have rounding at 20:00 and 23:00, but the following entry wasn't until 02:20 when the
patient was found, which illustrates missed hourly rounding. The toileting log also lacked entries
from 22:30 until the fall. Though the admission Morse Fall Scale score of 55 was documented,
reassessment at shift change or that the fall precautions were re-taught weren't documented.
The bed alarm had not been last cleaned in over six months, and no pre-shift check was
documented. Handoff reports did not include the patient's recent unassisted ambulation
attempts, and patient education for fall risk was not documented, and informed refusal was not
documented. The incident report lacked time-stamped entries for pre-fall checks, which made
root-cause analysis challenging. These documentation shortfalls led to real and perceived
breakdowns in policy, introduced additional legal risk, and reduced the hospital's ability to
detect prevention opportunity oversights.
4. Who was involved?: Staff (Directly Involved)
o Staff: Identify the roles of The charge nurse at the bedside was responsible for monitoring fall precautions, rounding, and
individuals directly bed alarm checking but was distracted with a patient experiencing a respiratory crisis and
involved in the event. therefore had delayed monitoring and no documented reassessment of risk for falls. The
o Supervisors and Managers: nursing assistant, who was assisting the distressed patient as well, failed to toileting as assigned
Investigate at 2:00 a.m., likely prompting the patient's self-ambulation. The charge nurse, although not
directly assigned, was responsible for staffing coordination but did not redistribute
responsibilities when both staff members were off-duty. Cumulatively, these role-specified
failures left the fall-risk patient alone and resulted in the fall.
Supervisors and Managers (Indirectly Involved)
Unit nurse management had a responsibility for staffing and compliance with fall prevention but
did not recruit to a sick-call vacancy, resulting in an under-staffed night shift. There was no
contingency plan put in place, and recent audits of bed alarm checking and rounding
documentation were not carried out. Refresher training on the use of bed alarms had not been
offered by the clinical educator in more than a year, and competency assessments were in
arrears for numerous staff members. Risk management was only activated when the incident
3
Understanding What Happened
1. What happened?: Begin by An 82-year-old male with pneumonia, hypertension, and mild cognitive impairment was
understanding the sequence of admitted to the medical-surgical unit. Despite being at high risk for falls (Morse Fall Scale = 55),
events leading up to the sentinel the patient attempted to ambulate unassisted to the bathroom at 2:15 a.m. on the third night
event. Gather detailed information of admission. His bed alarm was not functioning properly, and it failed to alert staff. The night
about the incident, including nurse and the assistant were occupied with another patient in respiratory distress, and the
the timeline, people involved, charge nurse was at the station. Due to the overwhelming nurse-to-patient ratio (1:8), hourly
and context. rounding was delayed, and the patient was left alone. Approximately five minutes later, a nurse
o Who did the found him on the floor next to the bathroom. On examination, there was a shortened,
problem/event affect, and externally rotated right leg, consistent with a hip fracture. Radiology confirmed a fracture of the
how? right femoral neck that required surgery.
Whom did the problem/event affect, and in what manner?
The patient had a fracture of the hip that required surgery, which caused him severe pain,
immobility, emotional distress, and a prolonged hospital stay of 10 extra days. His risks of
developing complications such as infection, delirium, and pneumonia were significantly
heightened. For the family, there was a loss of trust in the hospital's safety procedures, with
meetings with risk management being undertaken. The healthcare team experienced moral
distress, guilt, and workload created by incident reporting, which negatively impacted staff
morale and staff trust in fall-prevention systems. At an organizational level, the event caused
added expense from surgery and extended care, was classified as a sentinel event, and exposed
the hospital to lawsuits and loss of reputation.
2. Why did it happen?: The fall was caused by numerous human, system, and cultural problems. Handoff
o Human Factors: Investigate communication failure meant that prior unassisted ambulation attempts were not highlighted,
whether communication and the patient was not properly educated about his fall risk. Delayed rounding was the result
breakdowns, staff fatigue, of staff exhaustion from excessive patient loads (1:8 ratios) and understaffing. Training gaps and
or lack of improper bed alarm use heightened risk. System issues included workflow strain,
training contributed. malfunctioning equipment, inadequate lighting, and environmental hazards. Inadequate safety
o System Factors: culture, lack of proactive staffing, and alarm fatigue lowered adherence. The patient's cultural
1
, Examine workflow expectation of independence also deterred him from summoning assistance.
processes, equipment
failures,
and environmental factors.
o Organizational Culture:
Assess if there are cultural
issues, lack of safety
culture, or inadequate
leadership support.
o Society/Culture: What role
might cultural
assumptions or
backgrounds play?
3. Was there a deviation from Hospital protocol requires aggressive fall-prevention measures in high-risk patients (Morse ≥
protocols or standards?: 45), including: activated bed/chair alarms, call bells within reach with patient education,
o Procedures and Policies: prominent signs, two-hour scheduled toileting, hourly rounding, and repeat fall risk evaluation
Determine if at each shift handoff. In this case, there were several deviations. The bed alarm was broken and
established protocols were hadn't been inspected in over six months; a pre-shift functionality check by staff was also
followed or if there were neglected. The patient did have a call bell but lacked reinforcement on its use and was opposed
deviations. to "bothering the nurses." Scheduled two-hour toileting was overlooked, with more than 3.5
o Were there any steps that hours between checks. Purposeful rounding was delayed because of workload and lacked
were not taken or did not documentation at intended intervals. While fall-risk signage was present, other cues like non-
happen as intended? slip socks and reminders were not. Re-assessment at handoff was omitted, and the night nurse
o Documentation: failed to re-assess the Morse score.
Review medical Other deviations included failure to escalate staffing needs during a respiratory crisis, no re-
records, nursing notes, and education following prior unassisted ambulation attempts, and delayed maintenance reporting
other relevant of alarm issues. Although post-fall protocol (evaluation, imaging, reporting) was followed,
documentation. preventive interventions were implemented variably. Overall, system deficiencies and policy
deviations significantly contributed to the adverse event.
2
, Documentation (what the records show and gaps identified)
Nursing documentation was assessed and found to be severely lacking. The electronic flowsheet
did have rounding at 20:00 and 23:00, but the following entry wasn't until 02:20 when the
patient was found, which illustrates missed hourly rounding. The toileting log also lacked entries
from 22:30 until the fall. Though the admission Morse Fall Scale score of 55 was documented,
reassessment at shift change or that the fall precautions were re-taught weren't documented.
The bed alarm had not been last cleaned in over six months, and no pre-shift check was
documented. Handoff reports did not include the patient's recent unassisted ambulation
attempts, and patient education for fall risk was not documented, and informed refusal was not
documented. The incident report lacked time-stamped entries for pre-fall checks, which made
root-cause analysis challenging. These documentation shortfalls led to real and perceived
breakdowns in policy, introduced additional legal risk, and reduced the hospital's ability to
detect prevention opportunity oversights.
4. Who was involved?: Staff (Directly Involved)
o Staff: Identify the roles of The charge nurse at the bedside was responsible for monitoring fall precautions, rounding, and
individuals directly bed alarm checking but was distracted with a patient experiencing a respiratory crisis and
involved in the event. therefore had delayed monitoring and no documented reassessment of risk for falls. The
o Supervisors and Managers: nursing assistant, who was assisting the distressed patient as well, failed to toileting as assigned
Investigate at 2:00 a.m., likely prompting the patient's self-ambulation. The charge nurse, although not
directly assigned, was responsible for staffing coordination but did not redistribute
responsibilities when both staff members were off-duty. Cumulatively, these role-specified
failures left the fall-risk patient alone and resulted in the fall.
Supervisors and Managers (Indirectly Involved)
Unit nurse management had a responsibility for staffing and compliance with fall prevention but
did not recruit to a sick-call vacancy, resulting in an under-staffed night shift. There was no
contingency plan put in place, and recent audits of bed alarm checking and rounding
documentation were not carried out. Refresher training on the use of bed alarms had not been
offered by the clinical educator in more than a year, and competency assessments were in
arrears for numerous staff members. Risk management was only activated when the incident
3
