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Volume 20, Issue 3 (May - June 2021)                   Payesh 2021, 20(3): 295-300 | Back to browse issues page

Ethics code: IR.IUMS.REC.1398.1077

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Ahmadi Teymourlouy S A, Choopani A, Unesi kjnaghahi S, Bayazian G, rostam pour S, tazari R. Root Cause Analysis of Falling out of bed in one of the Pediatric Hospitals in Tehran in 2019-2020. Payesh. 2021; 20 (3) :295-300
URL: http://payeshjournal.ir/article-1-1417-en.html
1- School of Health Management & Information Sciences Iran University of Medical Sciences, Tehran, Iran
2- School of Medicine ENT and Head & Neck Research Center, Tehran, Iran
3- Ali Asghar Teaching Hospital, Iran University of medical sciences. Tehran, Iran
Abstract:   (761 Views)
Objective (s): Children are one of the most vulnerable groups in falls from hospital beds, because usually this might cause head injurie. There are limited researches to prevent children from falling. Therefore, this study was performed to analyze the roots cause factors affecting the fall in children.
Methods: This was a cross-sectional study. First the adverse events were measured using a monthly error recording form, then the root cause analysis of the problem was performed in six steps, problem identification, team formation, preparation of initial information and final map, identification of causes and drawing tables, identification of solutions and implementation and assessment of solutions.
Results: Lack of effective training of patient companions, old hospital beds, short, and long distance between bed railings, training of nurses, and controlling of the restless children were obtained as a root causes based on futuristic barrier analysis. The solutions were identified and implemented and the comparison of statistics before and after the implementation of the strategies showed that the rate of falling from the bed in the third quarter of the year has reached to zero percent.
Conclusion: Educating the patient companions about the keeping of the bed railings high and not leaving the child can have a great impact on reducing falls. Also, standardizing hospital beds, providing fall prevention guidelines for nurses, training the effective communication skills, and identifying high-risk children can help to reduce falls and injuries.
Full-Text [PDF 381 kb]   (214 Downloads)    
type of study: Research | Subject: Helath Service Manager
Received: 2020/08/2 | Accepted: 2021/06/21 | ePublished ahead of print: 2021/06/28 | Published: 2021/07/3

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