1. Introduction to Root Cause Analysis

2. Can falls be prevented?
The risk of falls and the harm caused as a result can be significantly reduced but they can never be eliminated entirely. Falls may still occur sometimes.

3. Can all falls be prevented?

4. What does everyone want and need?
Resident/person who has fallen Family Care Home Manager Care Home staff HM Coroner CQC

5. Possible Consequences of a Fall?
Distress for the person who has fallen and their relatives. Possible long term injury or even death. Adverse publicity for the Care Home or Organisation. Possible financial implications. A complaint from the family. Potential criticism from the Coroner and CQC. Loss of trust in the organisation and in individuals.

6. Consequences for Staff
Distress and upset for the individual who has fallen. Feelings of guilt and self-doubt. Loss of confidence in own abilities. Low morale. Fear of blame.

7. Everyone Wants… To understand: What happened? Why it happened?
What will be done to prevent the same thing from happening again?
Learning and improving.

8. Root Cause Analysis

9. Why Do Things Go Wrong?
Fatigue. Stress. Lack of training. Lack of understanding. Poor leadership. Inadequate resources. Poorly maintained equipment

10. Reporting and Recording
Learning and improving relies upon:
Clear and accurate reporting of events
Honesty in reporting
Timely reporting.
Accurate documentation of all events and circumstances at the time of the incident.

11. Report all trips, slips, slides and falls – regardless of how insignificant they may appear at the time!

12. The Benefits of RCA
Provides essential information for interested parties.
Helps relatives to understand what happened and why.
Provides an opportunity to further reduce the risks in the future.
Provides evidence that the event has been taken seriously and that action will be taken to improve all identified problems.
Reassures the staff of the things that they did well and gives confidence in the system.

13. What About Blame
Focusing on blame will NOT help to understand the facts.
It will NOT help to prevent further falls.
It will NOT help to establish a safety culture.

14. The Benefits of RCA Gives honest and comprehensive information.
Helps families to understand what happened and why.
Provides a realistic opportunity to evaluate and improve.
Provides evidence that the event has been taken seriously.
Reassures staff.

15. Remember, mistakes can happen, but…
To err is human
To cover up is unforgivable
To fail to learn is inexcusable
Sir Liam Donaldson
Chief Medical Officer