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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Requests for results of additional analyses from this aggregated root cause analysis should be directed to the corresponding author.
Scheffer AC, Schuurmans MJ, van Dijk N et al (2008) Fear of falling: measurement strategy, prevalence, risk factors and consequences among older persons. Age Ageing 37:19–24
Zijlstra GA, van Haastregt JC, van Eijk JT et al (2007) Prevalence and correlates of fear of falling, and associated avoidance of activity in the general population of community-living older people. Age Ageing 36:304–309
Denkinger MD, Lukas A, Nikolaus T et al (2015) Factors associated with fear of falling and associated activity restriction in community-dwelling older adults: a systematic review. Am J Geriatr Psychiatr 23:72–86
Deshpande N, Metter EJ, Lauretani F, Bandinelli S et al (2008) Activity restriction induced by fear of falling and objective and subjective measures of physical function: a prospective cohort study. J Am Geriatr Soc 56:615–620
Nilson F, Moniruzzaman S, Andersson R (2013) Fall-related fracture trends among elderly in Sweden—exoring transitions among hospitalized cases. J Saf Res 45:141–145
Karlsson MK, Magnusson H, von Schewelov T et al (2013) Prevention of falls in the elderly—a review. Osteoporos Int 24:747–762
Burns ER, Stevens JA, Lee R (2016) The direct costs of fatal and non-fatal falls among older adults—United States. J Saf Res 58:99–103
Aranda-Gallardo M, Morales-Asencio JM, Enriquez de Luna-Rodriguez M et al (2018) Characteristics, consequences and prevention of falls in institutionalised older adults in the province of Malaga (Spain): a prospective, cohort, multicentre study. BMJ Open 8:e020039
Pointer SC (2018) Trends in hospitalised injury, Australia 1999–00 to 2014–15. Injury research and statistics series No. 110. Cat. No. INJCAT 190. Canberra: Australian Institute of Health and Welfare
Baranzini F, Diurni M, Ceccon F et al (2009) Fall-related injuries in a nursing home setting: Is polypharmacy a risk factor? BMC Health Serv Res 9:228
Janus SIM, Reinders GH, van Manen JG et al (2017) Psychotropic drug-related fall incidents in nursing home residents living in the eastern Part of The Netherlands. Drugs R D 17:321–328
Dijcks BP, Neyens JC, Schols JM et al (2005) Falls in nursing homes: on average almost two per bed per year, resulting in a fracture in 1.3%. Ned Tijdschr Geneeskd 149:1043–1047
Gruneir A, Bell CM, Bronskill SE et al (2010) Frequency and pattern of emergency department visits by long-term care residents–a population-based study. J Am Geriatr Soc 58:510–517
Finn JC, Flicker L, Mackenzie E et al (2006) Interface between residential aged care facilities and a teaching hospital emergency department in Western Australia. Med J Aust 184:432–435
Lalic S, Sluggett JK, Ilomaki J et al (2016) Polypharmacy and medication regimen complexity as risk factors for hospitalization among residents of long-term care facilities: a prospective cohort study. J Am Med Dir Assoc 17:1067.e1-.e6
Renom-Guiteras A, Uhrenfeldt L, Meyer G et al (2014) Assessment tools for determining appropriateness of admission to acute care of persons transferred from long-term care facilities: a systematic review. BMC Geriatr 14:80
Kada O, Brunner E, Likar R et al (2011) From the nursing home to hospital and back again… a mixed methods study on hospital transfers from nursing homes. Z Evid Fortbild Qual Gesundhwes 105:714–722
Australian Commission on Safety and Quality in Health Care (ACSQHC) (2009) Guidebook for preventing falls and harm from falls in older people: Australian residential aged care facilities. https://www.safetyandquality.gov.au/wp-content/uploads/2009/01/30454-RACF-Guidebook1.pdf. Accessed 22 March 2019
Stubbs B, Schofield P, Binnekade T et al (2014) Pain is associated with recurrent falls in community-dwelling older adults: evidence from a systematic review and meta-analysis. Pain Med 15:1115–1128
Gale CR, Cooper C, Aihie Sayer A (2016) Prevalence and risk factors for falls in older men and women: the English longitudinal study of ageing. Age Ageing 45:789–794
Muir SW, Gopaul K, Montero Odasso MM (2012) The role of cognitive impairment in fall risk among older adults: a systematic review and meta-analysis. Age Ageing 41:299–308
Tinetti ME, Speechley M, Ginter SF (1988) Risk factors for falls among elderly persons living in the community. N Engl J Med 319:1701–1707
Mazur K, Wilczynski K, Szewieczek J (2016) Geriatric falls in the context of a hospital fall prevention program: delirium, low body mass index, and other risk factors. Clin Interv Aging 11:1253–1261
Pendlebury ST, Lovett NG, Smith SC et al (2015) Observational, longitudinal study of delirium in consecutive unselected acute medical admissions: age-specific rates and associated factors, mortality and re-admission. BMJ Open 5:e007808
Deandrea S, Bravi F, Turati F et al (2013) Risk factors for falls in older people in nursing homes and hospitals: a systematic review and meta-analysis. Arch Gerontol Geriatr 56:407–415
Jansen S, Bhangu J, de Rooij S et al (2016) The association of cardiovascular disorders and falls: a systematic review. J Am Med Dir Assoc 17:193–199
Kvelde T, McVeigh C, Toson B et al (2013) Depressive symptomatology as a risk factor for falls in older people: systematic review and meta-analysis. J Am Geriatr Soc 61:694–706
Hartikainen S, Lonnroos E, Louhivuori K (2007) Medication as a risk factor for falls: critical systematic review. J Gerontol A Biol Sci Med Sci 62:1172–1181
Machado-Duque ME, Castano-Montoya JP, Medina-Morales DA et al (2018) Association between the use of benzodiazepines and opioids with the risk of falls and hip fractures in older adults. Int Psychogeriatr 30:941–946
de Vries M, Seppala LJ, Daams JG et al (2018) Fall-risk-increasing drugs: a systematic review and meta-analysis: I. Cardiovascular drugs. J Am Med Dir Assoc 19:371.e1-.e9
Seppala LJ, Wermelink A, de Vries M et al (2018) Fall-risk-increasing drugs: a systematic review and meta-analysis: II. Psychotropics. J Am Med Dir Assoc 19:371.e11-.e17
Seppala LJ, van de Glind EMM, Daams JG et al (2018) Fall-risk-increasing drugs: a systematic review and meta-analysis: III. Others. J Am Med Dir Assoc 19:372.e1-.e8
Ouslander JG, Bonner A, Herndon L et al (2014) The Interventions to Reduce Acute Care Transfers (INTERACT) quality improvement program: an overview for medical directors and primary care clinicians in long term care. J Am Med Dir Assoc 15:162–170
Mills PD, Neily J, Luan D et al (2005) Using aggregate root cause analysis to reduce falls. Jt Comm J Qual Patient Saf 31:21–31
Shaqdan K, Aran S, Daftari Besheli L et al (2014) Root-cause analysis and health failure mode and effect analysis: two leading techniques in health care quality assessment. J Am Coll Radiol 11:572–579
Rooney JJ, Vanden Heuvel LN (2004) Root cause analysis for beginners. Qual Prog 37:45–53
Cerniglia-Lowensen J (2015) Learning from mistakes and near mistakes: using root cause analysis as a risk management tool. J Radiol Nurs 34:4–7
Neily J, Ogrinc G, Mills P et al (2003) Using aggregate root cause analysis to improve patient safety. Jt Comm J Qual Saf 29:434–439
Government of South Australia (SA Health) (2013) Root Cause Analysis (RCA). https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/safety+and+quality/governance+for+safety+and+quality/root+cause+analysis+rca. Accessed 14 Mar 2019
Tan EC, Visvanathan R, Hilmer SN et al (2014) Analgesic use, pain and daytime sedation in people with and without dementia in aged care facilities: a cross-sectional, multisite, epidemiological study protocol. BMJ Open 4:e005757
Theou O, Sluggett JK, Bell JS et al (2018) Frailty, hospitalization, and mortality in residential aged care. J Gerontol A Biol Sci Med Sci 73:1090–1096
Sluggett JK, Ilomaki J, Seaman KL et al (2017) Medication management policy, practice and research in Australian residential aged care: current and future directions. Pharmacol Res 116:20–28
World Health Organization (2019) Falls. Violence and Injury Prevention. https://www.who.int/violence_injury_prevention/other_injury/falls/en/. Accessed 21 Mar 2019
Korhonen MJ, Ilomaki J, Sluggett JK et al (2018) Selective prescribing of statins and the risk of mortality, hospitalizations, and falls in aged care services. J Clin Lipidol 12:652–661
Harvey N, Holmes CA (2012) Nominal group technique: an effective method for obtaining group consensus. Int J Nurs Pract 18:188–194
Harris PA, Taylor R, Thielke R et al (2009) Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 42:377–381
Milos V, Bondesson A, Magnusson M et al (2014) Fall risk-increasing drugs and falls: a cross-sectional study among elderly patients in primary care. BMC Geriatr 14:40
Latino RJ, Flood A (2004) Optimizing FMEA and RCA efforts in health care. J Healthc Risk Manag 24:21–28
Guirguis-Blake JM, Michael YL, Perdue LA et al (2018) Interventions to prevent falls in older adults: updated evidence report and systematic review for the us preventive services task force. JAMA 319:1705–1716
Berry SD, Placide SG, Mostofsky E et al (2016) Antipsychotic and benzodiazepine drug changes affect acute falls risk differently in the nursing home. J Gerontol A Biol Sci Med Sci 71:273–278
Song W, Intrator O, Lee S et al (2018) Antihypertensive drug deintensification and recurrent falls in long-term care. Health Serv Res 53:4066–4086
Trifiro G, Spina E (2011) Age-related changes in pharmacodynamics: focus on drugs acting on central nervous and cardiovascular systems. Curr Drug Metab 12:611–620
Corsonello A, Pedone C, Incalzi RA (2010) Age-related pharmacokinetic and pharmacodynamic changes and related risk of adverse drug reactions. Curr Med Chem 17:571–584
Ryan-Atwood TE, Hutchinson-Kern M, Ilomaki J et al (2017) Medication use and fall-related hospital admissions from long-term care facilities: a hospital-based case-control study. Drugs Aging 34:625–633
Clinical Excellence Commission (2015) The 5 × 5 Antimicrobial Audit: Pilot Project Evaluation. http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0020/282125/Pilot_Project_Evaluation.pdf. Accessed 5 Apr 2019
Cameron ID, Dyer SM, Panagoda CE et al (2018) Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev 9:Cd005465
McDerby N, Kosari S, Bail K et al (2019) The effect of a residential care pharmacist on medication administration practices in aged care: a controlled trial. J Clin Pharm Ther. https://doi.org/10.1111/jcpt.12822
Kosse NM, de Groot MH, Vuillerme N et al (2015) Factors related to the high fall rate in long-term care residents with dementia. Int Psychogeriatr 27:803–814
Yang Y, Feldman F, Leung PM et al (2015) Agreement between video footage and fall incident reports on the circumstances of falls in long-term care. J Am Med Dir Assoc 16:388–394
Grabowski DC, Stewart KA, Broderick SM et al (2008) Predictors of nursing home hospitalization: a review of the literature. Med Care Res Rev 65:3–39
Montalto M, Shay S, Le A (2015) Evaluation of a mobile X-ray service for elderly residents of residential aged care facilities. Aust Health Rev 39:517–521
Kjelle E, Lysdahl KB (2017) Mobile radiography services in nursing homes: a systematic review of residents’ and societal outcomes. BMC Health Serv Res 17:231
Jeanmonod R, Asher S, Roper J et al (2018) History and physical exam predictors of intracranial injury in the elderly fall patient: a prospective multicenter study. Am J Emerg Med. https://doi.org/10.1016/j.ajem.2018.10.049
Hamden K, Agresti D, Jeanmonod R et al (2014) Characteristics of elderly fall patients with baseline mental status: high-risk features for intracranial injury. Am J Emerg Med 32:890–894
Peerally MF, Carr S, Waring J et al (2017) The problem with root cause analysis. BMJ Qual Saf 26:417–422
Tricco AC, Thomas SM, Veroniki AA et al (2017) Comparisons of interventions for preventing falls in older adults: a systematic review and meta-analysis. JAMA 318:1687–1699
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.
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).
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). https://doi.org/10.1007/s40520-019-01407-z
- Residential aged care
- Long-term care
- Nursing home
- Root cause analysis