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ROOT CAUSE ANALYSIS AND FREQUENCY OF FALLINGS IN A UNIVERSITY HOSPITAL

Yıl 2011, Cilt: 27 Sayı: 3, 21 - 34, 01.11.2011

Öz

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

Kaynakça

  • Baker RG, Norton GP, Flintoft V, et al. (2004). The Canadian adverse events among hospital patients in Canada. CMA J, 170(11): 1678-1686
  • Berdot S, Bertrand M, Dartigues J, et al. (2009). Inappropriate medication use and risk of falls- a prospective study in a large community- dwelling elderly cohort. BMJ, 9(30):1-10
  • Bergeron E, Clement J, Lavoie A, et al. (2006). A simple fall in elderly: Not so simple. Journal of Trauma. Injury, Infection and Critical Care, 60(2): 268-273
  • Blegen MA, Vaughn T, Pepper G, et al. (2004). Patient and staff safety: voluntary reporting. Am. J. Med. Qual, 19(2): 67-74
  • Choi H (2008). Falls Among Older Adults: Characteristics of Fallers, Predictors of Falls, and The Impact of Falls on Health Care and Long-Term Care Utilization. South California University, Doktora Tezi, California
  • Currie LM (2004). Development and Testing of an Automated Fall-Injury Risk Assessment Instrument. Columbia University, Doktora Tezi, Amerika Birleşik Devletleri
  • Çakmakçı M (2003). Hasta güvenliği, tıbbi hatalar ve akreditasyon. Seminer Kitabı, İstanbul
  • Dempsey J (2004). Fall prevention revisited: a call for a new approach. Journal of Clinical Nursing, 13: 479- 485
  • Derrick DP (2008). Hospital Based Patient Falls: A Clinical Engineering Perspective. Wayne State University, Yüksek Lisans Tezi, Detroit, Michigen
  • Erdem DD, Eyüpoğlu LU, Cengiz C, ve ark. (2009). An evaluation of patient falls between the periods of June 2006 and June 2008. III Uluslararası Hasta Güvenliği Kongresi Kongre Kitabı, 173
  • Evans D, Hodgkinson B, Lambert L, et al. (2001). Falls risk factors in the hospital setting: A systematic review. International Journal of Nursing Practice, 7: 38-45
  • Fonda D, Cook J, Sandler V, et al. (2006). Sustained reduction in serious fall-related injuries in older people in hospital. Medical Journal of Australia, 168 (8): 379-382
  • Gablear (1993). Predicting which patient will fall again…..and again. Journal of Advanced Nursing, 18: 1895-1902
  • Gowdy M, Godfrey S (2003). Using tools to ases and prevent inpatient falls. Jt Comm J. Qual Saf, 29(7): 363-368
  • Heinze C, Halfens Rjg, Dassen T (2007). Falls in German in-patients and residents over 65 years of age. Journal of Clinical Nursing, 16: 495-501
  • Hill K, Black K, Haines T, et al. (2005). Commentary on prevention revisited: a call for a new approach. Journal of Clinical Nursing, 13: 479–485
  • Hitcho EB, Krauss MJ, Birge S, et al. (2004). Claiborne Dunagan W., Fischer I., Johnson S., ve ark. Characteristics and circumtances of falls in a hospital setting: a prospective analysis. Journal of General Internal Medicine, 19(7): 732-739
  • Joint Commission on Accreditation of Healthcare Organizations (2009). Falls are voluntarily reportable sentinel events. htpp://www.jointcomissioninternational.org. Erişim tarihi: 10.08.2010
  • Karataş KG, Maral I (2001). Ankara-Gölbaşı İlçesinde geriatrik popülasyonda 6 aylık dönemde düşme sıklığı ve düşme için risk faktörleri. Turkish Journal of Geriatrics, 4:152-158
  • Krauss MJ, Evanoff B, Hitcho E, et al. (2005). A case-control study of patient, medication, and care-related risk factors for inpatient falls. J Gen Intern Med, 20: 116–122.
  • Kurutkan NM (2009). İstenmeyen olaylara yaklaşım. III.Uluslararası hasta güvenliği kongresi 12 Haziran 2009, İstanbul, http://www.hastaguvenligimiz.com/dengelleme program.html Erişim tarihi: 13.02.2010
  • Lamb SE, Jorstad-Stein EC, Hauer K, et al. (2005). Development of a common outcome data set for fall injury prevention trials: the prevention of falls network Europe consensus. Journal of Geriatric Society, 53(9): 1618-1622
  • McKee J (2005). Root Cause Analysis in Health Care: Tools and Techniques. Second Edition, Newyork, Joint Commission Resources (JCR) Published
  • Morse JM (2009). Preventing patient falls. Second Edition, New York, Springer Publishing Company, www.springerpub.com/samples/9780826103895_chapter. pdf , Erişim Tarihi: 10.10.2010
  • O’Hagan C, O’Connell B (2005). The relationship between patient blood pathology values and patient falls in an acute-care setting: A retrospective analysis. International Journal of Nursing Practice, 11: 161–168
  • Özyurt F. (2008). Özel bir vakıf hastanesinde karşılaşılan istenmeyen olaylar ve bu olayların meydana gelmesini etkileyen faktörlerin belirlenmesi. Haliç Üniversitesi Sağlık Bilimleri Enstitüsü, Yüksek Lisans Tezi, İstanbul
  • Quality Improvement Committee Resources (2008). Commentary on Sentinel&Serious Events Reported by District Health Boards-2006/07, http://www.qic.health. govt.nz/moh.nsf/indexcm/qic-sentinel-and-serious- events-report-0607, Erişim Tarihi: 20.06.2009
  • Schaaf TW, Habraken MP (2005). PRISMA-Medical a brief description. Eindhoven: Eindhoven University of Tecnology, Faculty of Tecnology Management, Patient Safety Systems
  • Schwendimann R, Bühler H, De Geest S, et al. (2008). Characteristics of hospital inpatient falls across clinical departments. Gerontology, 54: 342-348
  • Sezgin B. (2007). Kalite belgesi alan hastanelerde çalışma ortamı ve hemşirelik uygulamalarının hasta ve hemşire güvenliği açısından değerlendirilmesi. İstanbul Üniversitesi Sağlık Bilimleri Enstitüsü, Doktora Tezi, İstanbul
  • Smits M, Janssen J, De Vet R, et al. (2009). Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and classifying root causes. International Journal for Quality in Health Care, 21(4): 292–300
  • Snijders C, Van der Schaaf TW, Klip H, et al. (2009). Feasibility and reliability of PRISMA-Medical for specialty-based incident analysis. Qual Saf Health Care, 18: 486-491
  • Tinetti ME (2003). Preventing falls in elderly persons. N Engl J Med, 348: 42-49.
  • Torres SL (2009). Impact of Hand-off Communication on Fall Reduction in an Inpatient Setting. Doktora Tezi, Capella University
  • Uden G, Ehnfors M, Sjöström K (1999). Use of initial risk assessment and recording as the main nursing intervention in identifying risk of falls. Journal of Advanced Nursing, 29(1):145-152
  • Williams PM (2001). Techniques for root cause analysis. BUMC ROCEEDINGS, 14: 154-157
  • World Health Organization (2005). Who draff guidelines for adverse event reporting and learning systems. www.who.int/entity/patientsafety/events/05/Reporting_Guidelines.pdf. Erişim tarihi:12.12.2009
  • Yang EYJ (2006). Characteristics and consequences of falls and risk factors for injuries due to inpatient falls for selected hospitals in Taiwan. Doktora Tezi, South Carolina University

BIR ÜNIVERSITE HASTANESINDE DÜŞMELERIN SIKLIĞI VE KÖK NEDEN ANALIZI

Yıl 2011, Cilt: 27 Sayı: 3, 21 - 34, 01.11.2011

Öz

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

Kaynakça

  • Baker RG, Norton GP, Flintoft V, et al. (2004). The Canadian adverse events among hospital patients in Canada. CMA J, 170(11): 1678-1686
  • Berdot S, Bertrand M, Dartigues J, et al. (2009). Inappropriate medication use and risk of falls- a prospective study in a large community- dwelling elderly cohort. BMJ, 9(30):1-10
  • Bergeron E, Clement J, Lavoie A, et al. (2006). A simple fall in elderly: Not so simple. Journal of Trauma. Injury, Infection and Critical Care, 60(2): 268-273
  • Blegen MA, Vaughn T, Pepper G, et al. (2004). Patient and staff safety: voluntary reporting. Am. J. Med. Qual, 19(2): 67-74
  • Choi H (2008). Falls Among Older Adults: Characteristics of Fallers, Predictors of Falls, and The Impact of Falls on Health Care and Long-Term Care Utilization. South California University, Doktora Tezi, California
  • Currie LM (2004). Development and Testing of an Automated Fall-Injury Risk Assessment Instrument. Columbia University, Doktora Tezi, Amerika Birleşik Devletleri
  • Çakmakçı M (2003). Hasta güvenliği, tıbbi hatalar ve akreditasyon. Seminer Kitabı, İstanbul
  • Dempsey J (2004). Fall prevention revisited: a call for a new approach. Journal of Clinical Nursing, 13: 479- 485
  • Derrick DP (2008). Hospital Based Patient Falls: A Clinical Engineering Perspective. Wayne State University, Yüksek Lisans Tezi, Detroit, Michigen
  • Erdem DD, Eyüpoğlu LU, Cengiz C, ve ark. (2009). An evaluation of patient falls between the periods of June 2006 and June 2008. III Uluslararası Hasta Güvenliği Kongresi Kongre Kitabı, 173
  • Evans D, Hodgkinson B, Lambert L, et al. (2001). Falls risk factors in the hospital setting: A systematic review. International Journal of Nursing Practice, 7: 38-45
  • Fonda D, Cook J, Sandler V, et al. (2006). Sustained reduction in serious fall-related injuries in older people in hospital. Medical Journal of Australia, 168 (8): 379-382
  • Gablear (1993). Predicting which patient will fall again…..and again. Journal of Advanced Nursing, 18: 1895-1902
  • Gowdy M, Godfrey S (2003). Using tools to ases and prevent inpatient falls. Jt Comm J. Qual Saf, 29(7): 363-368
  • Heinze C, Halfens Rjg, Dassen T (2007). Falls in German in-patients and residents over 65 years of age. Journal of Clinical Nursing, 16: 495-501
  • Hill K, Black K, Haines T, et al. (2005). Commentary on prevention revisited: a call for a new approach. Journal of Clinical Nursing, 13: 479–485
  • Hitcho EB, Krauss MJ, Birge S, et al. (2004). Claiborne Dunagan W., Fischer I., Johnson S., ve ark. Characteristics and circumtances of falls in a hospital setting: a prospective analysis. Journal of General Internal Medicine, 19(7): 732-739
  • Joint Commission on Accreditation of Healthcare Organizations (2009). Falls are voluntarily reportable sentinel events. htpp://www.jointcomissioninternational.org. Erişim tarihi: 10.08.2010
  • Karataş KG, Maral I (2001). Ankara-Gölbaşı İlçesinde geriatrik popülasyonda 6 aylık dönemde düşme sıklığı ve düşme için risk faktörleri. Turkish Journal of Geriatrics, 4:152-158
  • Krauss MJ, Evanoff B, Hitcho E, et al. (2005). A case-control study of patient, medication, and care-related risk factors for inpatient falls. J Gen Intern Med, 20: 116–122.
  • Kurutkan NM (2009). İstenmeyen olaylara yaklaşım. III.Uluslararası hasta güvenliği kongresi 12 Haziran 2009, İstanbul, http://www.hastaguvenligimiz.com/dengelleme program.html Erişim tarihi: 13.02.2010
  • Lamb SE, Jorstad-Stein EC, Hauer K, et al. (2005). Development of a common outcome data set for fall injury prevention trials: the prevention of falls network Europe consensus. Journal of Geriatric Society, 53(9): 1618-1622
  • McKee J (2005). Root Cause Analysis in Health Care: Tools and Techniques. Second Edition, Newyork, Joint Commission Resources (JCR) Published
  • Morse JM (2009). Preventing patient falls. Second Edition, New York, Springer Publishing Company, www.springerpub.com/samples/9780826103895_chapter. pdf , Erişim Tarihi: 10.10.2010
  • O’Hagan C, O’Connell B (2005). The relationship between patient blood pathology values and patient falls in an acute-care setting: A retrospective analysis. International Journal of Nursing Practice, 11: 161–168
  • Özyurt F. (2008). Özel bir vakıf hastanesinde karşılaşılan istenmeyen olaylar ve bu olayların meydana gelmesini etkileyen faktörlerin belirlenmesi. Haliç Üniversitesi Sağlık Bilimleri Enstitüsü, Yüksek Lisans Tezi, İstanbul
  • Quality Improvement Committee Resources (2008). Commentary on Sentinel&Serious Events Reported by District Health Boards-2006/07, http://www.qic.health. govt.nz/moh.nsf/indexcm/qic-sentinel-and-serious- events-report-0607, Erişim Tarihi: 20.06.2009
  • Schaaf TW, Habraken MP (2005). PRISMA-Medical a brief description. Eindhoven: Eindhoven University of Tecnology, Faculty of Tecnology Management, Patient Safety Systems
  • Schwendimann R, Bühler H, De Geest S, et al. (2008). Characteristics of hospital inpatient falls across clinical departments. Gerontology, 54: 342-348
  • Sezgin B. (2007). Kalite belgesi alan hastanelerde çalışma ortamı ve hemşirelik uygulamalarının hasta ve hemşire güvenliği açısından değerlendirilmesi. İstanbul Üniversitesi Sağlık Bilimleri Enstitüsü, Doktora Tezi, İstanbul
  • Smits M, Janssen J, De Vet R, et al. (2009). Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and classifying root causes. International Journal for Quality in Health Care, 21(4): 292–300
  • Snijders C, Van der Schaaf TW, Klip H, et al. (2009). Feasibility and reliability of PRISMA-Medical for specialty-based incident analysis. Qual Saf Health Care, 18: 486-491
  • Tinetti ME (2003). Preventing falls in elderly persons. N Engl J Med, 348: 42-49.
  • Torres SL (2009). Impact of Hand-off Communication on Fall Reduction in an Inpatient Setting. Doktora Tezi, Capella University
  • Uden G, Ehnfors M, Sjöström K (1999). Use of initial risk assessment and recording as the main nursing intervention in identifying risk of falls. Journal of Advanced Nursing, 29(1):145-152
  • Williams PM (2001). Techniques for root cause analysis. BUMC ROCEEDINGS, 14: 154-157
  • World Health Organization (2005). Who draff guidelines for adverse event reporting and learning systems. www.who.int/entity/patientsafety/events/05/Reporting_Guidelines.pdf. Erişim tarihi:12.12.2009
  • Yang EYJ (2006). Characteristics and consequences of falls and risk factors for injuries due to inpatient falls for selected hospitals in Taiwan. Doktora Tezi, South Carolina University
Toplam 38 adet kaynakça vardır.

Ayrıntılar

Birincil Dil Türkçe
Bölüm Özgün Araştırma
Yazarlar

Yıldız Mülayim Bu kişi benim

Şeyda Seren İntepeler Bu kişi benim

Yayımlanma Tarihi 1 Kasım 2011
Yayımlandığı Sayı Yıl 2011 Cilt: 27 Sayı: 3

Kaynak Göster

APA Mülayim, Y., & İntepeler, Ş. S. (2011). BIR ÜNIVERSITE HASTANESINDE DÜŞMELERIN SIKLIĞI VE KÖK NEDEN ANALIZI. Ege Üniversitesi Hemşirelik Fakültesi Dergisi, 27(3), 21-34.