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Posted: August 23rd, 2023

Root-Cause Analysis and Improvement Plan for Preventing Falls in

Root-Cause Analysis and Improvement Plan for Preventing Falls in Geropsychiatric Patients


In the realm of healthcare, patient safety is a paramount concern, and preventing adverse events like falls is a crucial aspect of ensuring high-quality care. Geropsychiatric patients, particularly those aged 65 and above, are especially vulnerable to falls, which can lead to severe injuries and complications. This article delves into a comprehensive root-cause analysis of falls in geropsychiatric patients, identifying key factors contributing to the issue and proposing evidence-based strategies and an improvement plan to enhance patient safety.

Understanding Root-Cause Analysis

Root-cause analysis is a systematic approach aimed at uncovering the underlying causes of adverse events and near misses. The process involves a thorough examination of incidents to identify factors that contributed to their occurrence, with the ultimate goal of implementing preventive measures (Spath, 2011, as cited in Charles et al., 2016). In the context of falls in geropsychiatric patients, this analysis seeks to illuminate the causes of falls and near-falls, providing a foundation for devising an effective improvement plan.

Identifying Causes of Falls in Geropsychiatric Patients

Falls are a pressing concern among geropsychiatric patients, often resulting in serious injuries such as fractures and head trauma. These incidents are particularly significant given their potential preventability (National Quality Forum, 2011, as cited in Powell-Cope et al., 2014). A meticulous review of 20 fall cases over a year in a geropsychiatric inpatient facility revealed that factors such as ambulation under the influence of drugs, generalized weakness, disorientation, and inadequate infrastructure were contributing to falls (Powell-Cope et al., 2014).

Role of Medication and Behavioral Factors

Geropsychiatric patients often take medications that increase the risk of falls. Drugs like antidepressants and antipsychotics can lead to conditions such as orthostatic hypotension and impaired motor functions, heightening the probability of falls (Powell-Cope et al., 2014). Behavioral factors like anxiety and the inability to call for help further exacerbate the risk.

Infrastructure and Environmental Considerations

Inadequate infrastructure also plays a significant role in falls among geropsychiatric patients. Most falls occurred near patients’ beds, indicating a need for bed- and chair-exit alarms and nonskid footwear (Powell-Cope et al., 2014). Environmental modifications, including signage, non-slip strips, and geriatric-friendly sanitary ware, can significantly enhance patient safety.

Evidence-Based Strategies for Fall Prevention

To effectively reduce falls, evidence-based strategies must be employed. Firstly, medication management is vital. Replacing sedatives like zolpidem with melatonin can help minimize sedation-related falls (Powell-Cope et al., 2014). Secondly, installing bed- and chair-exit alarms, especially for patients with cognitive impairments, proves to be effective in fall prevention (Wong Shee et al., 2014). Lastly, fostering a proactive approach through interdisciplinary collaboration and a dedicated quality and patient safety team can contribute to reducing sentinel events (Serino, 2015).

The Improvement Plan

The improvement plan involves two main aspects: enhancing staff effectiveness and coordination, and implementing environmental modifications. Staff training in intentional rounding and one-to-one patient observation aims to improve monitoring and prevent falls (Morgan et al., 2016). Environmental changes, including alarms and geriatric-friendly infrastructure, are essential for minimizing fall risks. Leveraging existing resources ensures cost-efficiency and minimal disruption.


Falls among geropsychiatric patients are a serious concern, but a systematic approach to root-cause analysis provides valuable insights into their causes. Evidence-based strategies and a comprehensive improvement plan can significantly enhance patient safety and reduce the occurrence of falls. By addressing medication management, environmental modifications, and staff coordination, healthcare facilities can effectively mitigate the risks associated with falls in geropsychiatric patients.


Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., . . . Hake, M. E. (2016). How to perform a root cause analysis for workup and future prevention of medical errors: A review. Patient Safety in Surgery, 10.

Morgan, L., Flynn, L., Robertson, E., New, S., Forde‐Johnston, C., & McCulloch, P. (2016). Intentional rounding: A staff‐led quality improvement intervention in the prevention of patient falls. Journal of Clinical Nursing, 26(1-2), 115–124.

Powell-Cope, G., Quigley, P., Besterman-Dahan, K., Smith, M., Stewart, J., Melillo, C., … Friedman, Y. (2014). A qualitative understanding of patient falls in inpatient mental health units. Journal of the American Psychiatric Nurses Association, 20(5), 328–339.

Serino, M. F. (2015). Quality and patient safety teams in the perioperative setting. AORN Journal, 102(6), 617–628.

Wong Shee, A., Phillips, B., Hill, K., & Dodd, K. (2014). Feasibility, acceptability, and effectiveness of an electronic sensor bed/chair alarm in reducing falls in patients with cognitive impairment in a subacute ward. Journal of Nursing Care Quality, 29(3), 253–262.


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