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A fall story
• A 61 years-old man diagnosed with a
diagnosis of small cell lung carcinoma
suffered a fall during his stay ...
Fox cerebri
hematoma
Hematoma
Fox cerebri and
right ventricule
Enoxaparine
40 mg/dayMorphine
and Pain-
Killers
Platelets:
76000
Fall hitting the
head
RCA summarized
Patient with lung cancer, under prophylactic
heparin (40 mg/day) and platelets 76000
suffered a fall during...
Fish Bone diagram
Fall.
Hitting
the head
No visual
control
No “holding”
railing
No asking
For permission
“no medical
event...
Analysis and Improvement proposals
• 1. An oncologic patient under psychotropic drugs, with
muscular atrophy and a weak ge...
A Root Cause Analysis of a Fall
A Root Cause Analysis of a Fall
A Root Cause Analysis of a Fall
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A Root Cause Analysis of a Fall

A simple event as a fall of a patient inside the hospital help to improve safety and reduce suffering

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A Root Cause Analysis of a Fall

  1. 1. A fall story • A 61 years-old man diagnosed with a diagnosis of small cell lung carcinoma suffered a fall during his stay at the hospital . A CAT scan showed a subdural hematoma located in the fox cerebri and right lateral ventricule. • An analysis based in the Reason model and a summarized Root cause analysis is proposed.
  2. 2. Fox cerebri hematoma
  3. 3. Hematoma Fox cerebri and right ventricule
  4. 4. Enoxaparine 40 mg/dayMorphine and Pain- Killers Platelets: 76000 Fall hitting the head
  5. 5. RCA summarized Patient with lung cancer, under prophylactic heparin (40 mg/day) and platelets 76000 suffered a fall during a walk The use of psychotropic drugs, less nutrient and muscle atrophy were associated to the fall A low platelets value, heparin and an strong head trauma were asociated with the intracranial bleeding. Analysis and recommendations
  6. 6. Fish Bone diagram Fall. Hitting the head No visual control No “holding” railing No asking For permission “no medical event”?Nurses? Lack of communication STRUCTURE PROCESS FUNCTIONS No alarm when psychotropics
  7. 7. Analysis and Improvement proposals • 1. An oncologic patient under psychotropic drugs, with muscular atrophy and a weak general situation is at high risk for a fall when he or she start to walk again. • 2. This simple situation must be under control: the healthcare team must be informed when the patient is going to start walking. An auxilliary nurse must be attending. An orthopedic help must be considered to facilitate walking. • 3. The combination of psychotropics, pain killer and heparin is a risky combination when the patient start walking .

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