ROOT CAUSE ANALYSIS AND FREQUENCY OF FALLINGS IN A UNIVERSITY HOSPITAL

Year 2011, Volume: 27 Issue: 3, 21 - 34, 01.11.2011

Yıldız Mülayim Şeyda Seren İntepeler

Abstract

Objective: This study has been made as a descriptive evaluation for the purpose of understands the root cause analyses and frequency of fallings in a university hospital. Methods: No sampling was made in the study. The study population included patients falling down in all clinics of a university hospital between March-August 2010 N=61 . The dates were collated by “Falling Inpatient Notification Form” developed by researchers and consisted of six parts. Eindhoven Classification Model and number, percent distribution, mean and kappa cohesion analysis was used in analyses of the data. Results and Conclusion: 33.4% of the patients are between 61-75 ages and the mean is 62.2 SS=1.55 . Over half of the patients 52.5% were female, and a small proportion 19.7% had a previous history of falling accident for one or more times. 32.8% of the patients were fallen in the first three days. 36.3% of the fallings were seen between 04-08 a.m. 54.1% of the fallings happened in the patient room. In 32.78% of the fallings resulted in injury. The mean falling ratio of the hospital was %0.33 and neurology clinic had the highest ratio with %1.54. The most common causes of the fallings were patient’s carelessness 32.8% , physical status of the patient 32.8% , lack of patient relatives 22% . Causal trees were formed for each falling. Totally 241 root cause was defined and 34 root cause were found for each falling. The causal trees were found to be patient related factors 45% , rule-based behaviors errors 23% technical 15.8% and organizational 8% errors. In light with the obtained results, it could be suggested to take right, convenient and peculiar precautions by evaluating the reasons of falling accidents through risk evaluation scale in patients falling or with high risk of falling. In this context, it is recommended to the falls and risk assessment committees should be established to monitoring patient falls at the institutional level, evaluating the results of the falls and improving the prevention

Keywords

Patient safety, patient falls, causes of falls, root cause analysis, Eindhoven

BIR ÜNIVERSITE HASTANESINDE DÜŞMELERIN SIKLIĞI VE KÖK NEDEN ANALIZI

Abstract

Amaç: Çalışma, bir üniversite hastanesinde düşmelerin sıklığını ve kök nedenlerini belirlemek amacıyla tanımlayıcı olarak gerçekleştirilmiştir. Gereç ve Yöntem: Araştırmada örneklem seçimine gidilmemiş, Mart-Ağustos 2010 tarihleri arasında üniversite hastanesinin tüm kliniklerinde meydana gelen hasta düşmeleri araştırma örneklemini oluşturmuştur N=61 . Araştırmanın verileri, araştırmacılar tarafından oluşturulan ve altı bölümden oluşan “Düşen Hasta Bildirim Formu” ile toplanmıştır. Verilerin analizinde sayı-yüzde dağılımları, ortalama ve kappa uyum analizi ile Eindhoven Sınıflandırma Modeli kullanılmıştır. Bulgular ve Sonuç: Hastaların, %34.4’ü 61-75 yaş grubundadır ve yaş ortalaması 62.2 SS=1.55 ’dir. Hastaların yarısının %52.5 kadın olduğu ve %19.7’sinin daha önce bir veya daha fazla kez düşme öyküsü olduğu belirlenmiştir. Düşmelerin %32.8’inin hastaneye yatışın ilk üç günü içinde ve %36.1’inin 04:01-08:00 saatleri arasında gerçekleştiği belirlenmiştir. Düşmelerin %54.1’inin hasta odasında olduğu saptanmıştır. Düşen hastaların %32.78’inde yaralanma meydana geldiği belirlenmiştir. Hastanede düşme oranının %0.33 olduğu ve en yüksek düşme oranının nöroloji kliniğinde %1.54 meydana geldiği bulunmuştur. Düşme nedenleri sırasıyla; hastanın dalgınlık ve dikkatsizliği %32.8 , hastanın fiziksel durumu %32.8 , refakatçi olmaması %22 ’dır. Her bir düşme için neden ağaçlarının yapılması sonucu 241 kök neden tanımlanıp sınıflandırılmıştır ve her olay için 3-4 kök neden ortaya çıkarılmıştır. En çok düşmeler hastaya bağlı faktörler %45 , kural kaynaklı hatalar %23 , teknik %15.8 ve organizasyonel %8 hatalar nedeniyle gerçekleşmiştir. Elde edilen sonuçlar doğrultusunda; düşme riski yüksek olan veya düşen hastalarda, risk değerlendirme ölçeği ile hastaların düşme nedenleri değerlendirilerek, doğru, uygun ve hasta bireye özgü önlemlerin alınması önerilebilir. Bu kapsamda, kurumsal düzeyde hasta düşmelerini izleyen, sonuçlarını değerlendiren ve önlemler geliştiren düşme ve risk değerlendirme komitelerinin kurulması sağlanmalıdır

Keywords

Hasta güvenliği, hasta düşmeleri, düşme nedenleri, kök neden analizi

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