Related Experiment Video
Updated: May 25, 2026
08:05
Design and Analysis for Fall Detection System Simplification
Published on: April 6, 2020
Using root cause analysis to reduce falls with injury in the psychiatric unit
Alexandra Lee1, Peter D Mills, Bradley V Watts
1Veterans Affairs National Center for Patient Safety Patient Safety Fellowship, White River Junction VA Medical Center, White River Junction, VT 05009, USA. alexandra.lee@va.gov
General Hospital Psychiatry
|January 31, 2012
Summary
Falls in psychiatric units often happen when patients get up, walk, or during bathroom activities. Key causes include environmental hazards and poor risk communication, with staff education and better documentation being effective solutions.
Area of Science:
- Psychiatric nursing
- Patient safety research
- Healthcare quality improvement
Background:
- Falls are a significant safety concern in psychiatric units.
- Understanding fall mechanisms and root causes is crucial for prevention.
Purpose of the Study:
- To identify how falls occur on psychiatric units.
- To determine the underlying root causes of these falls.
- To outline effective action plans for reducing falls and injuries.
Main Methods:
- Conducted a search of the Veterans Health Administration National Center for Patient Safety database.
- Included 75 root cause analysis (RCA) reviews of falls on psychiatric units from January 2000 to March 2010.
Main Results:
- Identified 138 actions from RCA reports.
- Common fall activities: getting up from bed/chair/wheelchair (21.3%), walking/running (10.7%), bathroom (9.9%), behavior-related (9.9%).
- Primary root causes: environmental hazards (11.2%), poor fall risk communication (8.9%), inadequate equipment (8.9%), and assessment system flaws (8.9%).
- Frequent actions taken: staff education (19.9%), improved documentation tools (17.0%), and falls prevention equipment (14.2%).
Conclusions:
- The study details fall circumstances, activities, and root causes in psychiatric units.
- Provides insights for implementing successful fall reduction action plans.
