Hospital : Island Hospital – Paediatric Ward

Month : July
Year : 2021

ROOT CAUSE ANALYSIS

Care
Management Risk Reduction Action Plan
Incident Contributing causes/RCA Outcome
Problem (RRAP)
(CMP)
1. Report No : Fall Method Method Unit Sister to
RN : 10-017024 Patient had a fall while walked out Reinforce to patient not to move around educate / retrain
Date : 16/07/2021 without assistant from toilet by himself if feel unwell all nurses on the
Brief Details: importance of fall
Process Process management.
A 16 year old boy admitted with Hypospadius Patient fall Staff assisted patient to toilet and Staff to teach and check on the
Fistula in room 311-2 had a fall on his way out informed patient to press call-bell functioning of call-bell before left patient in Unit Sister
from toilet. when ready to go back to bed toilet emphasize to all
SN F (5 years experience) assisted patient to to test the
toilet (patient have CBD) for pass motion and People People functioning of call
asked patient to press call bell when ready. RN left patient in toilet as taught can RN to ensure toilet call bell is functioning bell upon
Patient claimed that he pulls the call bell string call by call bell without realize the before left patient alone in toilet providing room
but no one came (call-bell string was struck). call bell was spoilt. facility orientation.
He then walked out from toilet himself and Patient was advised to wait for assistance
suddenly felt giddy. Managed to lean against Patient walked out himself after before walked out from toilet
cardiac table and sit on floor. press the toilet call bell and no one
The child was seen by MO with scratch mark attended to him for sometimes. Policy
seen at left upper arm. Patient suddenly felt giddy Staff were re-in forced on IPSG No 6
Paediatric fall risk assessment done on while walked out from toilet ( Reduce the Risk of Patient Harm Result
admission with score of 9 (low risk) from Falls)
Reassessment done with score of 13 (high Policy
risk). IPSG No 6 ( Reduce the Risk of Measurement
Patient Harm Result from Falls) Patient to adhere to fall prevention advice
Patient was reinforced not to move around at all times
without assistance. Staff was advised to stayed Measurement
with patient and accompanied patient back to Risk Score: 9 on admission Environment
bed. Risk Score: 13 after fall Staff to test the call bell upon teaching the
patient trigger the nurse call
Environment
Toilet call bell was faulty without
staff knowledge

Prepared By Verified By Acknowledged By

Ms. Ching Bee Bee / Ms. Gooi Chung Ling Ms. Christine Amelia Ms Stephanie Lee Wai Fern
Charge Nurse / Matron Director of Nursing Chief Operating Officer
Patient fall

METHOD PROCESS PEOPLE

Patient fall Patient went to toilet RN / Patient

RN left patient in toilet as taught can call

Patient had a fall while walked out without
assistant from toilet
Staff assisted patient to toilet and
informed patient to press call-bell when
ready to go back to bed
by call bell without realize the call bell
was spoilt.
Patient walked out himself after press the
toilet call bell and no one attended to him
for sometimes. Patient suddenly felt
giddy while walked out from toilet
Patient fall

IPSG No 6 ( Reduce the Risk of Risk Score: 9 on admission Toilet call bell was faulty without
Patient Harm Result from Falls) Risk Score: 13 after fall staff knowledge

IPSG No 6 Fall risk Call bell faulty

POLICY MEASUREMENT ENVIRONMENT