Analysis of the Root Cause
Analysis of the Root Cause
Certain medications, like high potency pain medicine, sleeping aids, and opioids affect the mental state and interfere with balance and stability. (Seppala et al. 2018) The purpose of this RCA is to investigate the patients who take these medicines and incur bruises or broken bones after these medications led to their falling and getting injured. (Brullo et al. 2022) Many studies link opioid usage to the incidence of falls and fractures in the elderly population. According to an article in the America Journal of Nursing and the CDC, more than half of elderly people “used at least one medication in 2013 whose adverse effects were linked to falls.” (Haddad et al. 2018) When these patients fall, not only are they hurt, but the nurse and hospital suffer due to costs rising from longer hospital stays or maybe even lawsuits. Elderly patients who fall have a higher propensity for more health complications as well, such as pressure ulcers due to immobility after the fall, and even depression when they are limited in their ability to perform activities and feel powerless.
Hospitalized patients already have a higher chance of falling due to cluttered hospital rooms, with bedside tables, commodes, or IV poles blocking paths. Some of these patients may already have issues with balance or lack of coordination, and so are at additional risk for falling. There are many other risk factors for falling in the hospital setting, like being elderly and female, having a history of alcoholism, and the use of certain medicines like antidepressants or anti-psychotics. Hospital organizations must take all the precautions to try and greatly reduce any risks of falling for their patients and by putting these necessary precautions, like using standardized fall risk assessments and bed or chair alarms, they are making great efforts in reducing these tragedies. (Brullo et al. 2022)
