• Peter D Mills, Julia Neily, Diana Luan, Erik Stalhandske, and William B Weeks.
• Field Office, VA National Center for Patient Safety, White River Junction, Vermont, USA. Peter.Mills@med.VA.gov
• Jt Comm J Qual Patient Saf. 2005 Jan 1;31(1):21-31.

BackgroundIn certain categories of adverse events, Department of Veterans Affairs (VA) facilities may combine data to produce an aggregate review of the data. Individual root cause analyses are still required for the more serious adverse events. About 100 of the VA acute and long term care facilities contributed data to an analysis of results of 176 root cause analyses (RCAs) for patient falls occurring in the VA system.MethodsSuccess was measured through a decreased report of falls and major injures due to falls after each organization's action plans were implemented. In addition, telephone interviews were conducted to understand success factors as well as barriers to implementation of clinical improvements.ResultsOf the 745 actions generated (that addressed the root cause), 435 (61.4%) had been fully implemented and another 148 (20.9%) had been partially implemented; 34.4% of the facilities reported reducing falls and 38.9% reported reducing major injuries due to falls.DiscussionThe action plans associated with these reductions focused on making specific clinical changes at the bedside rather than policy changes or educating staff. Specific interventions most highly associated with reductions in falls and injuries included environmental assessments, toileting interventions, and interventions that directly addressed the root cause and were the responsibility of a single person (as opposed to a group).

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