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Root-Cause Analysis and Safety Improvement Plan

Root-cause analysis or RCA is a method of discovering the root causes of problems so that solutions can be generated and implemented to rectify the situation in the future. (Martin-Delgado et al. 2020) This paper will analyze the risk of falls associated with medication administration in the inpatient setting. The core elements and root cause of this potentially dangerous safety issue will be uncovered and discussed, and ways to prevent these unfortunate and preventable events will be offered.

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)

Improvement Plan

This proposed improvement strategy includes the assessment and intervention to ensure the safe administration of opioids and other balance-altering medicines. It also plans for the safest possible environment for the patient in the minutes and hours following that dispensation. First and foremost, it is vital that all members of the interdisciplinary team are involved in this process. The many doctors, pharmacists, physical therapists, unit managers, and nurses will meet to discuss proper patient screening, creating safe environments, continuing education availability about the various pharmacology, and the very important conversation about intentional rounding and proper staff management. (Ryan et al. 2019)

Each patient, upon admission, should be thoroughly screened to assess the significance of their risk of falling. Areas that should be explored include mobility, visual acuity, mental state, issues with continence, and blood pressure fluctuations. Patient rooms must be free from clutter, appropriately lit, and most importantly, the call button must be within reach and this should be checked and rechecked constantly throughout each shift.

Continuous education for doctors, nurses, and other staff about safety and medication administration must be encouraged. Policies and science are always changing, and anyone involved in patient care must be up to date on every nuanced change. Nurses should stay continuously updated on all drug knowledge by doing their own reading, attending informational presentations, and constantly asking questions of the providers or pharmacists. Not knowing relevant information about medications that one gives can prove detrimental to patient safety.

Finally, and perhaps most importantly, after any medication is administered that can affect a patient’s balance or ability to function optimally, it is imperative that the patient be monitored every 15 minutes for the first hour, and then checked on with intentional rounding for the remainder of the shift and during the entire hospital stay. Just having an hourly rounding schedule in place can mean the difference between a patient’s safety or unfortunate outcomes. (Ryan et al. 2019)

Existing Organizational Resources

Current hospital personnel would be creating this safer system for preventing falls, so no additional costs would pose a problem with that. There may be the need to hire an instructor for a few informational sessions for the staff to review safety practices and how it pertains to medication administration. Aside from standard fall risk precautions mentioned previously, the hospital system should purchase non-skid socks, identification tag bracelets that indicate the patient is a fall risk, and clearer signage so patients are not confused. Bed and chair alarms will continue to be used and are usually part of the hospital’s standard costs. If there is room in the budget, video monitoring may prove extremely helpful in discovering what may have caused a fall in that instance and how best to avoid it in the future. It could prove very beneficial to hire more staff, like “sitters”, to be with patients who are at the highest risk of falling. (Greeley et al. 2020)


There is a myriad of approaches to avoiding falls resulting from improper medication administration. Nurses and staff must stay educated and alert to any changes or improvements in the pharmacology field. They need to know when and how often to check on their patients and make sure to leave their room only after ensuring the environment is clean and safe. When the hospital is tuned in to patient safety and ensures the environment is conducive to avoiding falls, and the staff understands the importance of watching for any risk, the patient will have a much better and safer hospital stay.


Brullo, J., Rushton, S., Brickner, C., Madden-Baer, R., Peng, T. (2022). Using root cause analysis to inform a falls practice change in the home care setting. Home Healthcare Now 40 (1), 40-48. Doi: 10.1097/NHH.0000000000001036

Greeley, A.M., Tanner, E.P. Mak, S., Begashaw, M.M., Miake-Lye, I.M., Shekelle, P.G. (2020). Sitters as a patient safety strategy to reduce hospital falls: A systematic review. Annals of Internal Medicine 172 (5), 317-324.

Haddad, Y.K., Bergen, G., Luo, F. (2018). Reducing fall risk in older adults. AJN The American Journal of Nursing 118 (7), 21-22.

Martin-Delgado, J., Martinez-Garcia, A., Aranaz, J.M., Valencia-maritn, J.L., Mira, J.J. (2020). How much of root cause analysis translates into improved patient safety: A systematic review. Medical Principles and Practice 29 (6), 524-531.

Ryan, L, Jackson, D., Woods, C., Usher, K. (2019). Intentional rounding-An integrative literature review. Journal of Advanced Nursing 75 (6), 1151-1161.

Seppala, L.J., Van de Glind, E.M.M., et al. (2018). Fall-risk-increasing drugs: A systematic review and meta-analysis: 111. Others. Journal of the American Medical Directors Association 19 (4), 372. E1-372. E8.

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