Using Root Cause Analysis to Inform a Falls Practice Change in the Home Care Setting

Area of Science:

• Gerontology
• Public Health
• Healthcare Quality Improvement

Background:

• Falls are a major health issue for community-dwelling older adults, leading to injuries, mortality, and increased healthcare expenses.
• Falls presented a quality concern for a home care agency, prompting an evaluation of their falls prevention strategies.

Purpose of the Study:

• To evaluate the effectiveness of the falls prevention process for older adults receiving home care.
• To identify root causes of falls and determine necessary practice changes within the agency.

Main Methods:

• A quality improvement project utilizing root cause analysis (RCA) and a retrospective matched case-control design.
• Patient records were assessed for falls prevention process fidelity and compared between fallers and non-fallers, matched on the Missouri Alliance for Home Care-10 (MAHC-10) assessment.
• Analysis focused on care plan accuracy and the addressing of patient fall risk factors.

Main Results:

• Significant concerns were identified regarding fidelity in the falls prevention process.
• Gaps existed in care planning, with interventions not consistently aligned with identified patient fall risk factors.
• Specific risk factors like polypharmacy and pain affecting function were frequently unaddressed in care plans, with interventions present less than 50% of the time for four key factors.

Conclusions:

• The current falls prevention process in home care requires improvement to enhance patient safety.
• Recommendations include implementing a standardized falls prevention pathway, ensuring comprehensive risk assessment, and tailoring interventions to address identified risk factors effectively.