Caduta accidentale di una paziente sottoposta a riduzione chirurgica di frattura di femore: analisi delle cause profonde

Introduction. Inpatient falls in hospital is a relevant problem. The first essential step is to know the risks to prevent them, through reactive or proactive analysis. In this study we used the Root Causes Analysis (RCA) to analyze an accidental fall of a 79-year-old patient after a surgical intervention for a femoral fracture. The aim of the analysis is to evaluate the effect of this method on sanitary professionals. Material and methods. The study was conducted at the Operative Unity of Orthopaedics and Traumatology, “Beato Matteo Institute”, Vigevano. RCA was realised in the following steps: creation of the team, individuation of the causes, collection and evaluation of the information, identification of the solutions and the proposals of improvement. Results. The RCA showed the following causes: incomplete assessment of the patient, lacking professional skills, lacking of procedures and safety systems, risk factors connected both to the patient and the environment. The improvement proposals were: education and information of professionals, education of patient and caregivers, nursing interventions, environmental strategies and signalling systems. Discussion. RCA is an useful tool for risk management and it allowed to highlight causes and corrective actions of the accidental fall. Furthermore, this case allowed to underline advantages and disadvantages of this method. Advantages were the involvement of different professionals and sharing of objectives of systems improvement; the importance of the introduction of new instruments for risks identification and specific education to use them. Among the disadvantages we can list: difficulties in finding all the informations to correctly analyse the case, perception of too much bureaucracy in the procedure, and fear of a “punitive” use of the information collected