Root cause analysis of fall-related hospitalisations among residents of aged care services
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ORIGINAL ARTICLE
Root cause analysis of fall‑related hospitalisations among residents of aged care services Janet K. Sluggett1,2 · Samanta Lalic1 · Sarah M. Hosking1,3 · Jenni Ilomӓki1,4 · Terry Shortt5 · Jennifer McLoughlin5 · Solomon Yu3,6,7 · Tina Cooper5 · Leonie Robson5 · Eleanor Van Dyk8 · Renuka Visvanathan3,6,7 · J. Simon Bell1,2,3,4 Received: 21 October 2019 / Accepted: 30 October 2019 © Springer Nature Switzerland AG 2019
Abstract Background Fall-related hospitalisations from residential aged care services (RACS) are distressing for residents and costly to the healthcare system. Strategies to limit hospitalisations include preventing injurious falls and avoiding hospital transfers when falls occur. Aims To undertake a root cause analysis (RCA) of fall-related hospitalisations from RACS and identify opportunities for fall prevention and hospital avoidance. Methods An aggregated RCA of 47 consecutive fall-related hospitalisations for 40 residents over a 12-month period at six South Australian RACS was undertaken. Comprehensive data were extracted from RACS records including nursing progress notes, medical records, medication charts, hospital summaries and incident reports by a nurse clinical auditor and clinical pharmacist. Root cause identification was performed by the research team. A multidisciplinary expert panel recommended strategies for falls prevention and hospital avoidance. Results Overall, 55.3% of fall-related hospitalisations were among residents with a history of falls. Among all fall-related hospitalisations, at least one high falls risk medication was administered regularly prior to hospitalisation. Potential root causes of falling included medication initiations and dose changes. Root causes for hospital transfers included need for timely access to subsidised medical services or radiology. Strategies identified for avoiding hospitalisations included pharmacygenerated alerts when medications associated with an increased risk of falls are initiated or changed, multidisciplinary audit and feedback of falls risk medication use and access to subsidised mobile imaging services. Conclusions This aggregate RCA identified a range of strategies to address resident and system-level factors to minimise fall-related hospitalisations. Keywords Falls · Residential aged care · Long-term care · Nursing home · Hospitalisation · Root cause analysis
* Janet K. Sluggett [email protected] 1
Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia
2
NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Hornsby, NSW, Australia
3
Centre of Research Excellence in Frailty and Healthy Ageing, National Health and Medical Research Council of Australia, Adelaide, SA, Australia
4
Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
5
Resthaven Incorporated, Adelaide, SA, Australia
6
Adelaide Geriatrics Training and Research with Aged Care
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