Using root cause analysis to protection for patients from falling

26^th World Congress on Nursing Care

May 21-23, 2018 Osaka, Japan

Li-Fen Lin

Kaohsiung Hospital, Taiwan

Posters & Accepted Abstracts: J Nurs Care

Abstract :

Aim: The purpose of medical treatment is to relieve the pain and injury of the patient, but many patients get injured and sometimes even death results directly or indirectly in the medical processes due to negligence. This article was to describe the use of Root Cause Analysis (RCA) for identifying the possible causes of an adverse event involved with hyperglycemia due to falls caused by intracranial hemorrhage events, the use of RCA to find the root cause and improve the program, to provide medical staff attention and prevention. Method: As a serious and sentinel event, an investigation team was established. Key participants were identified and an RCA was implemented systematically with a trained facilitator guiding each analysis step. Chronological narratives were tabulated in a timeline sheet. Why tree and barrier analysis were used to determine the root factors of this event. Result: Three root causes of the patient with hyperglycemia due to falls f event were identified, which included: (1) Personal factors: Not really to implement assessment note of the new patient, (2) does not develop hyperglycemia care standards and (3) relevant education and training inadequate. Conclusion & Significance: RCA is a tool for improving the effectiveness of hospital medical abnormalities. For example, a patient-centered care model should not just follow the needs of the patient, the caregiver should have knowledge of the care of the disease and explain that it cannot match the patient's request to prevent a similar situation from happening again.

Biography :

Li-Fen Lin is a Registered Nurse of Municipal Hospital in Taiwan. She has five years clinical experience in hepatobiliary, gastroenterology, chest medicine, infection and oncology care.
Email:yuh3850@gmail.com