INVESTIGATION OF THE FREQUENCY OF PATIENT FALLS BY ROOT CAUSE ANALYSIS: KAYSERİ CITY HOSPITAL SAMPLE

Abstract

In the present study, it is aimed to do root cause analysis with finding out the frequency of patients’ falls and also finding out the factors that cause patients taking inpatient treatment. The target population of the study contains the patients’ falls occurring in all clinics at Kayseri City Hospital on 01.01.2019-31.12.2019. As a descriptive research, sampling is not applied to this research, root cause analysis is done by evaluating the falls of patients who have fallen while taking inpatient treatment in the sample years. In the research, the data is gathered by Fall Notification Form. To evaluate collected data by statistical analysis, SPSS-22 program is used. While descriptive analysis is being presented, percentage distribution, arithmetic mean, standard deviation, median, minimum- maximum values are used. While analysis and explicating is being done PRISMA method is used and also benefited from EINDHOVEN Classification method. For root cause analysis cause trees are done by asking a series of cause questions with the method of five causes and in total 262 root causes are found. For each case 2-4 root causes appear. From 81 patients, 28 of them(%34,6) are woman, 53 of them (%65,4) are men, the age average of th patients is calculated 64 +-17.6 ( standard deviation 17.6) age median is 67(min:3,5-max:93). On the basis of the clinic, the most fallen patients with the rate of %25,9 fall in the physical therapy and rehabilitation clinic. While %78 of fallen patients are major, 3 patients are evaluated at low risk. In the sample years, totally 120.935 patients’ rate is admitted to the hospital. Fallen patients’ rate is calculated as 0,07 among all other parts of the hospital. It is defined that 36 of fallen patients do not have companion, despite 45 of them have companion they are alone at falling moment. In root cause analysis of fallen cause, 15 of 262 faults are classified as hidden faults, 4 of them human faults and 243 of the faults are classified as other faults.