Root-Cause Analysis of an Injurious Inpatient Fall on a 34-Bed Medical-Telemetry Unit
Student Name
School of Nursing and Health Sciences, Capella University
NURS-FPX4035: Enhancing Patient Safety and Quality of Care
Instructor Name
Month Day, Year
Root-Cause Analysis of an Injurious Inpatient Fall on a 34-Bed Medical-Telemetry Unit
At 0410 on a Tuesday, a nursing assistant found a 78-year-old man on the floor beside his bed on a 34-bed medical-telemetry unit. He had been admitted three days earlier with a heart failure exacerbation and was receiving intravenous furosemide twice daily; at 2245 the previous evening he received zolpidem 5 mg for sleep. He told the responding nurse he had been trying to reach the bathroom. Imaging confirmed a left femoral neck fracture. He underwent surgical repair, his stay extended by nine days, and he was discharged to a skilled nursing facility rather than to the home where he had lived independently. No one witnessed the fall.
The event is not isolated. Over the twelve months ending June 30, the unit recorded 54 falls across 13,140 patient days, a rate of 4.1 falls per 1,000 patient days against a comparable-unit benchmark near 3.4. Twelve of the 54 caused injury, a rate of 0.9 injurious falls per 1,000 patient days, and two of the twelve were major. Falls with injury sit in a reviewable sentinel event category, and The Joint Commission has directed organizations to analyze them for the causes that repeat rather than for the individual who happened to be present (The Joint Commission, 2015). Reviewed against that instruction, seven of the twelve injurious falls in this window occurred between 0000 and 0600, and five of the seven involved a patient on either a diuretic or a sedative-hypnotic.
This analysis follows the standard root-cause sequence: establish what happened, then what should normally have happened, then which barriers were absent or defeated, and only then state the cause (The Joint Commission, 2017). What should normally have happened is written in the unit's own policy. A patient scored at moderate risk on admission is placed on universal fall precautions, has a bed exit alarm activated overnight, is offered toileting on a scheduled round, and is rescored every shift. What actually happened is that the admission score of 45 on the Morse Fall Scale was carried forward unchanged through six shifts, the bed exit alarm was charted as active but was found switched off, and the call light was clipped to the rail on the side away from the patient.
Analysis of the Root Cause
The proximate cause is easy to name and insufficient on its own. A patient with nocturnal urgency from a twice-daily intravenous diuretic received a sedative-hypnotic at 2245 and attempted an unassisted transfer five hours later. The medication pairing is well described in the fall literature: sedative-hypnotics raise fall risk in older inpatients, and combining one with a drug that guarantees a night-time trip to the bathroom compounds the exposure. Stopping the analysis here produces the finding most fall reviews produce, which is that the patient should have called for help. That finding cannot be acted on, because it locates the cause inside a sedated 78-year-old at four in the morning rather than inside a process the unit controls.
Three barriers were available and none of them held. The bed exit alarm was charted as active at 2300 and was found in the off position after the fall, a failure the unit's own alarm reports predict: staff silence alarms during care and reactivate them from memory. The call light was in the room but not within reach, which is precisely the failure scheduled rounding exists to catch. The reassessment barrier failed in a different way. Nothing in the record was wrong; the score was simply never rerun, because the unit's tool prompts reassessment at admission and at shift start, and this patient's risk changed at 2245, four and a half hours into a shift that had already asked its question.
The handoff carried the same design flaw forward. The outgoing nurse reported the patient as ambulating with a walker and independent with toileting during the day, an accurate statement that carried no fall risk score and no mention of the sleep medication ordered for that evening. The root cause therefore reads as a process statement rather than a personal one: because fall-risk reassessment on this unit is scheduled by clock and by admission rather than triggered by the events that change risk, a patient whose risk changed at 2245 continued to be cared for at 0410 under a plan written for a lower-risk patient. Every barrier that failed failed downstream of that single design decision, which is what makes it the root rather than one more contributing factor.
Safety Improvement Plan and Existing Organizational Resources
The evidence supports a multifactorial plan and specifically does not support a single-technology fix. LeLaurin and Shorr's review of the state of the science reports that bed alarms used as a stand-alone intervention have not reduced falls in the trials that tested them, while multifactorial programs carrying real implementation support have (LeLaurin & Shorr, 2019). The strongest recent trial is the Fall TIPS work, in which a patient-centered toolkit tying each identified risk factor to a matched intervention and to the patient's own understanding produced roughly a 15 percent reduction in falls and a reduction of about one third in falls with injury across fourteen units (Dykes et al., 2020). AHRQ's hospital falls toolkit supplies the operational form for both findings (Agency for Healthcare Research and Quality, 2013).
The plan converts the root cause into a trigger. In weeks 1 and 2, informatics adds an event-triggered reassessment task that fires on administration of any sedative-hypnotic, on any new or changed diuretic order, on any change in mobility status, and on any room transfer. In weeks 1 through 4, every patient gets a bedside plan built with the patient in the Fall TIPS three-column form: the risk factor, the matched intervention, and the patient's own words for what to do instead. In weeks 2 through 6, a sixty-minute post-sedative safety round is added, with toileting offered, call light placed in the hand, bed low and locked, and path cleared. In weeks 4 through 8, the fall risk score and the time of its last reassessment become required fields in the bedside handoff tool rather than narrative.
Four measures carry the plan, all baselined on the twelve months described above: total falls per 1,000 patient days, target below 3.4 from a baseline of 4.1; injurious falls per 1,000 patient days, target 0.6 from 0.9; the proportion of sedative-hypnotic administrations followed by a documented reassessment within sixty minutes, target 90 percent; and handoff field completion, target 95 percent. None of it requires new funding, which is why the resources are worth naming honestly. The unit already has a fall prevention champion funded at four hours per pay period, a shared governance council that meets monthly, a clinical nurse specialist, pharmacy review of high-risk medications in patients over 65, physical therapy mobility consults, and the reporting system that produced the twelve-month data used here. A safety plan a unit can start on Monday with what it already owns is more reliable than one waiting on a capital request (Frankel et al., 2017).
References
Agency for Healthcare Research and Quality. (2013). Preventing falls in hospitals: A toolkit for improving quality of care (AHRQ Publication No. 13-0015-EF). Agency for Healthcare Research and Quality.
Dykes, P. C., Burns, Z., Adelman, J., Benneyan, J., Bogaisky, M., Carter, E., Ergai, A., Lindros, M. E., Lipsitz, S. R., Scanlan, M., Shaykevich, S., & Bates, D. W. (2020). Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries: A nonrandomized controlled trial. JAMA Network Open, 3(11), e2025889.
Frankel, A., Haraden, C., Federico, F., & Lenoci-Edwards, J. (2017). A framework for safe, reliable, and effective care [White paper]. Institute for Healthcare Improvement.
LeLaurin, J. H., & Shorr, R. I. (2019). Preventing falls in hospitalized patients: State of the science. Clinics in Geriatric Medicine, 35(2), 273-283.
The Joint Commission. (2015). Sentinel event alert 55: Preventing falls and fall-related injuries in health care facilities. The Joint Commission.
The Joint Commission. (2017). Framework for conducting a root cause analysis and action plan. The Joint Commission.
How this NURS FPX 4035 Assessment 2 example is structured
The order is the analysis itself. The paper opens with the event on a clock, because a NURS FPX 4035 Assessment 2 that summarizes an incident without times cannot then argue about sequence, and it immediately places that single event inside a twelve-month rate with its denominator so the reader can see whether the fall was an outlier or a pattern. The middle section separates what should have happened from what did, walks each failed barrier, and then commits to one root cause written as a because-therefore statement rather than a list. The final section moves from cause to plan: evidence first, including evidence about what does not work, then dated actions with owners, then four measures with baselines, then the resources the organization already owns. References close it.
NURS-FPX4035 Assessment 2 questions, answered
Does NURS-FPX4035 Assessment 2 require a real event from my workplace?
No, and using one creates a privacy problem you do not need. The instructions accept a scenario from your practice setting, a case supplied in the courseroom, or a composite you construct, as long as no patient or employer is identifiable. The paper above uses a composite built to carry a complete causal chain, which is easier to analyze than a half-remembered real event.
What is the difference between the root cause and a contributing factor?
A contributing factor made the event more likely. The root cause is the one you can remove and expect the pattern to change. In the sample, the sedative, the silenced bed alarm, and the out-of-reach call light are contributing factors; the reassessment schedule that ignores risk-changing events is the root, because fixing it changes all three.
How specific does the safety improvement plan have to be?
Specific enough to be started. Give each action an owner, a week range, and a measure with a baseline number and a target. A plan saying the unit will improve education and raise awareness scores as Basic no matter how well it is written, because a reader cannot tell what would actually happen on Monday morning.
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