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Root cause analysis of fall-related hospitalisations among residents of aged care services



Fall-related hospitalisations from residential aged care services (RACS) are distressing for residents and costly to the healthcare system. Strategies to limit hospitalisations include preventing injurious falls and avoiding hospital transfers when falls occur.


To undertake a root cause analysis (RCA) of fall-related hospitalisations from RACS and identify opportunities for fall prevention and hospital avoidance.


An aggregated RCA of 47 consecutive fall-related hospitalisations for 40 residents over a 12-month period at six South Australian RACS was undertaken. Comprehensive data were extracted from RACS records including nursing progress notes, medical records, medication charts, hospital summaries and incident reports by a nurse clinical auditor and clinical pharmacist. Root cause identification was performed by the research team. A multidisciplinary expert panel recommended strategies for falls prevention and hospital avoidance.


Overall, 55.3% of fall-related hospitalisations were among residents with a history of falls. Among all fall-related hospitalisations, at least one high falls risk medication was administered regularly prior to hospitalisation. Potential root causes of falling included medication initiations and dose changes. Root causes for hospital transfers included need for timely access to subsidised medical services or radiology. Strategies identified for avoiding hospitalisations included pharmacy-generated alerts when medications associated with an increased risk of falls are initiated or changed, multidisciplinary audit and feedback of falls risk medication use and access to subsidised mobile imaging services.


This aggregate RCA identified a range of strategies to address resident and system-level factors to minimise fall-related hospitalisations.

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Fig. 1

Data availability

Requests for results of additional analyses from this aggregated root cause analysis should be directed to the corresponding author.


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The authors acknowledge the contributions of expert panel members Peter Hayball, Stephen Simmons, Solomon Yu, Jasmin MacIntyre, Terry Shortt, Belinda Willshire, Leonie Robson, Jenny McLoughlin, Eleanor Van Dyk, Kelly Cairns, Adele Richards, Georgina Hughes, Sharon Vafiadis, and Greg Scarlett.


This study was funded by a grant from Resthaven Inc. and the Centre for Research Excellence in Frailty and Healthy Ageing. JKS and JI were supported by National Health and Medical Research Council (NHMRC) Early Career Fellowships. JSB is supported by an NHMRC Boosting Dementia Research Leadership Scheme Fellowship. The original cohort study from which data were derived was funded by the Alzheimer’s Australia Dementia Research Foundation via the Resthaven Inc. Dementia Research Award, with additional funding provided by Resthaven Inc.

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Corresponding author

Correspondence to Janet K. Sluggett.

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Conflict of interest

This study was funded by a grant from Resthaven Inc. and the Centre of Research Excellence in Frailty and Healthy Ageing. LR, TC, TS and JM are employed by Resthaven Inc. RV is a Board Director of Resthaven Inc. JKS was supported by an NHMRC Early Career Fellowship. SMH is supported by a Deakin University Dean's Research Postdoctoral Fellowship. JSB was supported by an NHMRC Boosting Dementia Research Leadership Scheme Fellowship.

Human and animal rights

Ethical approval for this study was obtained from the Monash University Human Research Ethics Committee (Project ID 11418).

Informed consent

Written informed consent for resident participation in the original cohort study had been obtained previously. Members of the expert panel provided written informed consent to participate in the root cause analysis.

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Sluggett, J.K., Lalic, S., Hosking, S.M. et al. Root cause analysis of fall-related hospitalisations among residents of aged care services. Aging Clin Exp Res 32, 1947–1957 (2020).

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  • Falls
  • Residential aged care
  • Long-term care
  • Nursing home
  • Hospitalisation
  • Root cause analysis