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Using Root Cause Analysis to Reduce Falls in Rural Health Care Facilities.


In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors.


Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). Rockville (MD): Agency for Healthcare Research and Quality; 2008 Aug.
Advances in Patient Safety.


Prevention of patient falls is a significant patient safety concern in both acute and long-term health care settings. West Virginia’s quality improvement organization, the West Virginia Medical Institute, worked collaboratively with the State’s Patient Safety Improvement Corps, a national training program cosponsored by the Agency for Healthcare Research and Quality (AHRQ) and the Department of Veterans Affairs, on an AHRQ Information Technology Implementation Grant to assist health care institutions in reducing their rate of patient falls. We have done this by training 300 health care workers in root cause analysis (RCA) and by encouraging health care facilities to implement their own falls prevention programs, in which RCA is an essential tool to discover the cause of the initial fall and find ways to prevent recurrences.

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