Publication Date
Spring 2025
Degree Type
Doctoral Project
Degree Name
Doctor of Nursing Practice (DNP)
Department
Nursing
First Advisor
Wei-Chen Wang Tung
Keywords
root cause analysis, fall prevention, older adults, skilled nursing, long-term care, quality improvement
Abstract
Falls in older adults are common and often have severe outcomes. They are the leading cause of fatal and non-fatal injuries among people aged 65 and older and continue to increase. Half of residents in nursing facilities fall annually, and one in every ten falls will lead to a severe injury. Federal regulations like the Centers for Medicare and Medicaid Services require long-term care (LTC) facilities to incorporate quality assurance performance improvement initiatives to address identified quality concerns in LTC facilities. Root cause analysis (RCA) can help clinicians identify several root causes of falls and guide clinicians in developing personalized approaches to preventing falls. This quality improvement (QI) project sought to implement the RCA process to reduce fall rates among skilled nursing and LTC residents aged 65 and older. A quasi-experimental design was employed, and fall rates were compared three months before and three months after the implementation of RCA. Results showed a reduction of 3.14 falls per 1000 bed days and no fall-related fractures three months after the implementation of RCA. The findings revealed a marginally significant difference in fall rates, and residents’ history of falls was a significant predictor of falls. Utilizing the RCA process decreases the incidence of falls among older adults. It assists clinicians in identifying intrinsic, extrinsic, and environmental root causes of falls, helping them to develop multifactorial fall prevention strategies.
Recommended Citation
Ranjo, Terrence, "Application of Root Cause Analysis for Fall Prevention: A Quality Improvement Initiative for Older Adults in a Skilled Nursing and Long-Term Care Facility" (2025). Doctoral Projects. 184.
DOI: https://doi.org/10.31979/etd.9teu-trqa
https://scholarworks.sjsu.edu/etd_doctoral/184
