title: Using root cause analysis to reduce falls with injury in community settings.
abstract: BACKGROUND
  Falls are a common occurrence for older adults living in the community that may lead to physical injury and psychological harm. The US Department of Veterans Affairs National Center for Patient Safety (NCPS) database contains root cause analysis (RCA) reviews that identify falls resulting in injury in the community and subsequent action plans that may be helpful to prevent future falls.
  
  
  METHODS
  A search of the NCPS-database identified RCA reviews where the patient (community-dwelling and long term care elders) fell in the community resulting in moderate to severe injury. Falls occurred in the home, community living center, outpatient clinic, recreational outing, outdoors, or in a vehicle. Thirty-six RCAs from October 2001 through August 2010 were included. Cases were coded on the basis of location of the fall, primary activity of the patient before/during the fall, root causes, action items, outcome measures, and effectiveness of each action.
  
  
  RESULTS
  Sixty-seven root causes resulting in 59 actions were identified from the RCA reports. Falls most frequently occurred in the patient's home (41.7%). The most common activities the individual was engaged in during a fill included getting up from the bed or chair/wheelchair (22.2%), walking (22.2%), and transportation in a wheelchair van (14.8%). Although many actions yielded improved outcomes, the only action that was significantly associated with improvement was changes made to the environment (p = .028). setting activity
  
  
  CONCLUSIONS
  The and surrounding fallsthat occur in the that occur in the community and that result in moderate to serious injury were identified along with the events' root causes. The extremely limited number of reports suggests that there may be missed opportunities to conduct an RCA for adverse events that occur among community-dwelling and long term care elders.
authors.affiliation: US Department of Veterans Affairs National Center for Patient Safety Fellowship, White River Junction VA Medical Center, White River Junction, Vermont, USA.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Lee
authors.forename: Peter D
authors.initials: PD
authors.lastname: Mills
authors.forename: Julia
authors.initials: J
authors.lastname: Neily
mesh_terms: D000058:Accidental Falls / Q000517:prevention & control* / Q000706:statistics & numerical data*; D003142:Communication; D004777:Environment; D006801:Humans; D008134:Long-Term Care / Q000706:statistics & numerical data; D012111:Residence Characteristics / Q000706:statistics & numerical data; D018570:Risk Assessment; D060891:Root Cause Analysis; D017751:Safety Management / Q000379:methods / Q000458:organization & administration* / Q000592:standards; D014481:United States; D014493:United States Department of Veterans Affairs / Q000706:statistics & numerical data; D014947:Wounds and Injuries / Q000453:epidemiology* / Q000517:prevention & control*