Case Analysis of Factors Contributing to Patient Falls

Abstract

Falls are a constant risk for patients in acute-care hospitals, which can lead to serious consequences. The purpose of this study was to examine hospital fall case studies and to learn the contributing factors for patient falls. This was achieved by conducting a secondary analysis of 11 fall case studies obtained from two previous studies. The fall cases used the Senior Falls Investigative Methodology (SFIM) approach, which provided detailed analysis of the circumstances surrounding the falls. A total of 549 contributing factors were identified in the 11 case studies, where major categories were classified according to the four different layers of defenses using Reason’s Swiss Cheese Model of Accident Causation (organizational factors, supervision, preconditions, and unsafe acts). Hospital policies, reduced supervision, disease processes, the environment, and patients transferring without assistance dominated the reasons for increased risk. Additional strategies were recommended for all layers of defense to reduce patient falls.