Root Cause Analysis of Falls Using the Fishbone Framework

  • 16 Pages
  • Published On: 18-11-2023


The clinical incident in the case study falls among the elderly population. Mrs. Plum fell to the side on her left hip, resulting in a fracture while being assisted in using the commode during the night shift. Falls in old age has been a factor of great concern all over the world. Falls are contributed to by various factors. The results of falls are normally fatal and can include serious injuries like the case of Mrs.Plum. Falls forms the basis of this paper. For instance, the paper uses a root-cause analysis tool, the fishbone model, to identify all the possible causes of falls in the elderly population. The report first justifies using the fishbone model over other root-cause analysis frameworks. They then analyze the causes of falls in subcategories as well as deeper causes of the condition. After various causative agents are identified, several interventions are suggested to be applied in a fall prevention plan to reduce or eliminate incidences of medication errors at home and in hospitals. The recommendations thus contain measures that can be used at home and in hospitals. Most healthcare providers' intervention is required, as more falls are recorded in care units relative to the general population. This paper provides a sure path to the elimination of falls among the elderly.

Justification of Chosen Framework

The framework chosen for this investigation is the fishbone. The fishbone diagram is used to identify the cause and effect relationships. Compared to the 5 Why's, a problem-solving and questioning technique is applied in determining cause and effect relationships (Korac & Simic, 2019). The fishbone diagram is a visual problem-solving technique that clarifies the relationship between the causes and effects. On most occasions, the fishbone is used by improving individuals to logically organize potential causes after good brainstorm (Korac & Simic, 2019). The fishbone is 9s a competent root-cause analysis tool. This is linked to several properties and functions that it does. First, the fishbone enables the summarization of possible high-level causes, unlike other root-cause analysis techniques. Besides, the fishbone technique stimulates the identification of deeper potential causes. Its competency is further contributed to by the ability to drill down for further root causes when used together with the 5 Why's technique. It enables a more detailed analysis of a specific problem, like in this case (Korac & Simic, 2019). The fishbone diagram presents all the possible causes of a problem. These are usually grouped into categories that are not only graphical but also systematic. This contributes to the rationale for choosing this technique for this root-cause analysis. The diagram resembles a fish's structure with the spine having different branches (Korac & Simic, 2019). These represent the various categories of problems as well as the list of specific issues of issues. The outermost chapter usually identifies the root cause of the problem. However, different rules regarding the number and nature of branches; this root-cause analysis applies to the man, machine, materials, methods, and measurements (Korac & Simic, 2019). Fishbone and 5 Why are differed basically on execution, and fishbone can be a way of applying the 5 Why's. When the fishbone is completed, analysis to identify the root cause of various causes is identified. The fishbone is undoubtedly one of the most powerful tools of quality used to determine a problem's root cause. The fishbone will enable identifying causes of issues besides developing CAPAs to curb the presenting problems (Korac & Simic, 2019). Whatsapp In the presented case study, the fishbone will be used to analyze and identify the root cause of falls. Mrs. Plum, the victim in the case study, is 81 years old and suffers from Norovirus. However, she is not a high fall risk. Besides, she records no limb pain or weakness, no dizziness or pins, and needles to limbs. From bed rail assessment and falls assessment, the patient could independently get on and off the bed besides managing to bear weight, mobilizing up to five meters with a frame. Despite these findings, the patient fell to the side, falling on her hip, resulting in a fracture. This presents a puzzle to identify the root cause of this fall. The fishbone technique is the most competent tool for this root-cause analysis as it identifies all the possible causes of the falls. Thus, it would be applied to identify the causes in terms of those contributed to by man, machine, materials, methods, and measurements.


Any inadvertent incidence of coming to the ground or a lower level can be termed as a fall. Fall-related injuries are normally fatal if not looked into. More seriously, in the elderly population, fall-related injuries can result in permanent disabilities and impairments. Falls are categorized as anticipated, unanticipated, or accidental falls. Gradual changes to the body resulting from various hazards in and around the home or hospital settings result in falls (Cooper, 2017). Medical conditions and medications can also contribute to falls. The prevalence of falls in care wards is three times higher than in the general population (Cooper, 2017). One in every three older people is noted to fall. Most of these falls result in injuries that, in worst instances, can be life-threatening. More in old age, falls are fatal. Fall prevention is thus inevitable. In the presented case study, the patient was assessed and found fit but stiff fell while being helped with a commode. This must have been contributed to by other factors. A root-cause analysis is important for understanding the cause of the incident. Fishbone framework would be of utmost importance to identifying all the possible causes of falls. Fishbone can identify intrinsic and extrinsic factors that contribute to patient falls (Korac & Simic, 2019).

The Fishbone Diagram

This is a cause and effect diagram. Through it, brainstorming to identify the possible causes of falls in Mrs. Plum will be made simpler. The chart provides a visual way to look at the problem. Relative to other techniques like the five whys tool, the fishbone is a more structured approach to brainstorming the root cause of falls among the elderly (Korac & Simic, 2019). At the end of the diagram, that is, the head of the fish shows the problem. The smaller bones are diverging from the spine's midline display the possible causes of the pain under various cause categories (Korac & Simic, 2019). Before and while applying the root cause diagram, the problem statement has to be agreed upon. This is written at the mouth of the "fish." It should be clear and specific. The problem should be defined in terms of solutions or interventions for curbing falls among old age. Major categories of the various causes of falls among the elderly should then be agreed-upon. These are written as branches from the main arrow or the spine of the "fish" (Korac & Simic, 2019). The major categories will be inclusive of equipment factors, human factors, and system factors. After this, there is brainstorming on all the possible causes of the falls will be of utmost importance. One should seek answers to inquiries, such as why the incident occurred. Each idea is given while the casual factor is written as a branch from the appropriate category. These are placed on the fishbone diagram. The causes can also be written in several places in cases related to various types (Korac & Simic, 2019). While still answering why the incident might have occurred, sub-causes are identified and written branching off from the cause branches. Deeper levels of the fall incident's possible causes are generated further and organized in order under the related cause categories. By doing this, identifying and addressing the root causes to prevent future falls will be enabled. The fishbone diagram will be used to keep the analysis team focused on the causes of fall rather than the falls' symptoms. Besides, the fishbone diagram will be drawn on a large dry paper or a flip chart. Enough space is left between the major categories on the map to accommodate the various minor causative agents of falls among the elderly. The five ways technology is used together with the fishbone model while asking questions to get the root cause of falls among the elderly (Korac & Simic, 2019). Various factors were put into consideration while seeking the root cause of the fall incident of Mrs. Plum. One of these was the time of fall. On most occasions, change of shifts from days to evenings is an important factor. Besides, the location of the fall was also considered. Witnesses such as the resident and aide for Mrs. Plum might have contributed directly or indirectly to Mrs. Plum's fall incident. Fishbone diagram

Equipment Factors

The Commode

The use of some equipment can sometimes result in falls. For instance, in the case study, the patient was being assisted to use the commode when she fell. Possibly, the fall that involved the use of the bedside commode must have resulted in an instance where the patient was left after being assisted to the bedside commode, possibly for privacy purposes (Callis, 2016). It would thus be important to inquire the nurse and other healthcare providers that were on duty that night to investigate and understand what really happened on the night of the incidents. This can also be linked to negligence of the healthcare provider that was helping the patient since considering her age; she was not supposed to be left alone. This is mostly associated with the medications supplied to the patient (Brown & Miltner, 2014). For instance, the patient was provided with codeine medication. Being an opioid analgesic, dizziness, and lightheadedness might have resulted. This can lead to falls among the elderly (Callis, 2016). Despite the fact that a bedside commode is usually of assistance to the elderly patients in a hospital, the same presents with quite a number of challenges. Notably, at night when patient rooms are poorly lit, the bedside commode acts as an obstacle right on the side of the bed. This can lead to the patient tripping and bumping onto the commode leading to falls. The type and specifications of a commode are also factors to be put to consideration, which probably might have not been the case with Mrs. Plum. Steel and aluminium commodes are distinct and have different impacts on the patient. Besides, commodes with padded seats also differ from those without padded seats and have different effects on the safety of an elderly patient in a hospital. Commodes are meant to ensure and improve the safety of patients in the hospital; however, if they are mishandled or improperly used, they can be the factor that jeopardizes a patient’s safe as was Mrs. Plum’s case.

Human Factors

Medication (Codeine)

People and staff managing old patients equally contribute to their resultant fall incidences.

One of the human factors contributing to falls among the elderly is poor reaction times (Callis, 2016). Medical officers, physiotherapists, nurses, pharmacists, and podiatrists are among the people and staff who can contribute to falls among the elderly. They contribute to these through poor management and treatment of falling risk factors (Brown & Miltner, 2014). In cases where the staff and health professionals use nonholistic, inconsistent, and ununified approaches to managing old patients, falls and fall-related injuries resulting are usually a possibility (Callis, 2016). Staffs generally have a part to play in the context of falls among the elderly population. Various factors in healthcare settings put patients at risk of falling. These are inclusive of but not limited to an unfamiliar environment, acute illness, surgeries, medications, treatments, and placement of various tubes and catheters. For this case, medications under the human factors must have led to the fall as the patient used codeine. Several medications contribute significantly to the incidents of falls. They are among the most common causes of this problem besides being the risk factors for adults' falls. In the case study, the patient was given codeine medication. Codeine is an example of opioid analgesics, which is among the group of drugs that increase fall risks by affecting the brain (Ward et al., 2019). Opioid use has an increased fall risk. Though used as a pain treatment option among older adults, the side effects are often fatal. Codeine and other opioid drugs result in life-threatening conditions such as breathing problems, these in worst instances, lead to fatalities such as deaths. Some of the resultant feelings due to opioid use include lightheadedness, dizziness, extreme sleepiness, and unresponsiveness (Ward et al., 2019). This might have been the case in the case study.

Near Misses

It would also be prudent to investigate training record statements, off duty rotas, incident forms, patient notes alongside other documents to try to understand what happened on the night of the incident. Patients notes might indicate what the healthcare providers might had missed out. Also, other details about the patient such as problems with eyesight might have also contributed to the incident. Also, she might have forgotten to wear her glasses. Her footwear might have equally contributed to the fall incident.

System Factors

Risk Assessment

There are many factors that increase the risk of falling in adults like Mrs. Plum. A risk assessment is not only necessary but should also be accurate. Some of the risk factors of falls among the elderly are inclusive of mobility problems, balance disorders, chronic illness and impaired vision (Perell et al., 2001). When Mrs. Plum was assessed, she was found to lack risk factors that could lead to falling except for arthritis. However, she was still noted to fall on her side. Possibly, this was an indicator of poor or inaccurate risk assessment by the healthcare provider that was on duty. Risk assessment checks to discover the likelihood of fall in a patient (Perell et al., 2001). Should a fall risk show a high risk of falling, the healthcare provider is usually needed to make recommendations of strategies that would prevent falls and reduce the chances of injury in the long run. However, this was not the case in the study. The assessment done did not show high risk of falls for Mrs.Plum. Besides, the little risk shown due to the diagnosis of arthritis was not addressed accordingly. No recommendations were made to prevent possible incidence of falls by the patient. The healthcare provider should have employed a risk assessment tool to determine the accurate possibility of fall by the patient (Perell et al., 2001). The Center for Disease Control and Prevention (CDC) has developed an approach known as the Stopping Elderly Accidents, Deaths and Injuries (STEADI) (Perell et al., 2001). This tool not only includes risk assessment but also screening and intervention measures that can reduce risks of falling. The healthcare providers should have conducted a proper risk assessment to determine the possibilities of falls by Mrs. Plum and thus recommend strategies that could have prevented the falling incidence. Lighting Since the incident occurred at night, it would be wise to investigate whether there was poor lighting in the room which might have contributed to the fall incident. A health care provider on duty can be interviewed to attain this information as a way of investigating the root cause analysis of the falling incident. Flooring Slippery floor could have also led to the falling incident. Investigations on potential occurrence of such incident would give insight into the possible causes of the fall. Apart from the floor being slippery, it could have also been uneven thus the patient might have tripped and fell.

Instigating Positive Changes

Measures and Benchmarks

t would be important to measure the efforts to improve quality to demonstrate whether the efforts have led to change as desired. Also, this would demonstrate whether the efforts have contributed to unintended results and if additional efforts would be needed to bring the processes back into the desired ranges. Good performance reflects good quality practice thus measuring quality improvement is necessary. The quality of health care is measured through the observation of structure, processes, and outcomes. Structure entails the accessibility, the availability as well as the quality of resources that are available. The resources are inclusive of health insurance, bed capacities of hospital, and number of health care providers. Quality Improvement Strategies Plan-Do-Study-Act (PDSA) and Six Sigma The PDSA model can be used to make positive changes in healthcare processes for effective outcomes. This model establishes a functional relationship between diversities in processes as well as outcomes. Various goals are answered when using PDSA. These are inclusive of the goals of the project, how to know whether the goal is attained as well as what direction would be taken when the goal is attained. The Six Sigma would ensure improvement, designing, as well as monitoring of process in health care settings to reduce waste whilst maximizing satisfaction. Route Cause Analysis This would ensure identification of trends and assess risk that can be applied should human error be expected. RCA would thus be efficient for understanding the root cause and thus appropriate direction be taken.


Appointments with a Doctor

One of the recommendations for a hospital environment is making appointments with a doctor. This applies to those individuals who are at high risk of falls like the elderly population. This should be the beginning of a fall prevention plan for such individuals. In a hospital setting, doctors should look for fall risk factors in all patients. They should hook out specific characteristics that are useful to the implementation of preventive measures (Li & Fitzgerald, 2016). The policies offer the best baseline for further patient risk assessments. Patient Orientation

Healthcare providers should always orient the patient to the hospital surroundings upon admission (Li & Fitzgerald, 2016). These should include orientations to the beds, bathrooms, surroundings; call bel, and tripping hazards in the surrounding. The nurses should answer call bells promptly. This would prevent unstable patients from ambulating promptly. Nurses should also ensure that basic elimination and personal needs, such as bathrooms, pain medication, and water or blankets, are adequately met (Li & Fitzgerald, 2016). Patients should be provided with proper mobility aids besides appropriate footwear. Communication with Patients

Communication with patients is vital. Healthcare providers should thus ensure this. Information such as when they leave or when they should be expected back is essential to the patients since they may need to move anytime. The patients' beds should be kept in the lowest position. This is more advised for sedated, unconscious or compromised patients. In instances where a patient is confused, healthcare providers should avoid using side rails as these may create a barrier that is climbed on and increase fall risk in such situations (Li & Fitzgerald, 2016). Sensitive and other frequently used essential items should be kept close to patients. This eases access to the articles by limiting movements that would instead increase fall risks (Li & Fitzgerald, 2016). Assisting Patients

Occasionally, a patient may fall while ambulating or during a transfer. When that occurs, a nurse or any other healthcare provider should avoid attempts to stop the patient from falling or to catch the patient (Zanker & Duque, 2020). Instead, he or she should lower the patient to the ground. This should be a stepwise procedure. First, the healthcare provider should move behind the patient and take one step back. After that, s/he should support the patient around the waist or hip area, bend his or her le and place it in between the patient's legs. The patient is then slowly slid down the leg while he or she is lowering him/herself too. The head should be protected first. After the patient is safely down, an assessment for any injuries before moving is conducted (Li & Fitzgerald, 2016).

Physical Activity

Another recommendation for a fall-prevention plan is engaging in physical activity (Li & Fitzgerald, 2016). These activities can include walking as well as water workouts. The activities have been found to reduce the risk of falling by enhancing the body's physical strength, balance, coordination, and flexibility. For the older population, carefully monitored exercise programs are advised. They are also advised to engage a physical therapist who would create a custom exercise program to achieve goals like flexibility and balance besides muscle strength and gait (Li & Fitzgerald, 2016).


Stairways and walkways should always be clear to efficient transitions from one point to another (Ocker et al., 2020). Pieces of Stuff such as boxes, loose rugs should be removed and spilled liquids dried upon notice. Loose wooden floorboards are also recommended to be repaired upon warning to avoid falls (Li & Fitzgerald, 2016). Living space should be well lit. Night lights should be placed in the bedroom, bathroom as well as hallways. The lamp should be placed within reach of the bed at night for inevitable night needs. Paths to light switches should be made clear at all times (Li & Fitzgerald, 2016). Before moving from one room to another, one should ensure that the lights are turned on. Flashlights are also recommended to be stored in places where they are easy to find in times of urgent need and cases of power outages. Assistive devices such as a cane or walkers are recommended to keep one steady. Occupational therapists are also advised to help brainstorm other strategies for fall prevention during old age (Li & Fitzgerald, 2016).

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Falls are among the leading causes of injuries among the elderly population. Understanding the root cause of falls is thus of utmost importance. This is done efficiently by applying an appropriate root-cause analysis tool. In this case, the fishbone model is chosen over other frameworks following its competency. Several possible causes of falls are identified (Korac & Simic, 2019). These consist of intrinsic factors, extrinsic factors, environmental factors, human factors, procedural, system factors, and equipment factors. After identifying the root causes of falls, recommendations are made on the most appropriate and evidence-based measures that can be put in place to ensure that falls amongst the elderly are a thing of the past. The listed implications are not the only hospital-based but also home-based. For instance, improving lightning can be done both at home and in the hospital (Ocker et al., 2020). It has also been noted that when a patient is falling, they should not be prevented but instead helped down so that they land safely, priority being given to the head. The Fishbone framework is ideal for identifying the root cause of a problem. It is thus recommended for different issues. Applying the recommendations is also an important motive. Besides, more research should be done on the root cause of falls and possible interventions for eliminating it.

Dig deeper into Roles and Responsibilities of Registered Nurses in Healthcare with our selection of articles.


Brown, C. J., & Miltner, R. S. S. (2014). Hospital Falls. In Patient Safety (pp. 197-210). Springer, New York, NY.

Callis, N. (2016). Fall prevention: Identification of predictive fall risk factors. Applied nursing research, 29, 53-58.

Chen, K. H., Chen, L. R., & Su, S. (2010). Applying root cause analysis to improve patient safety: decreasing falls in postpartum women. BMJ Quality & Safety, 19(2), 138-143. Cooper, R. (2017). Reducing falls in a care home. BMJ Open Quality, 6(1).

Cumming, R. G. (1998). Epidemiology of medication-related falls and fractures in the elderly. Drugs & Aging, 12(1), 43-53.

Fraenkel, N. A., Goldstein, G., Sarig, I., & Haddad, R. (2004). U.S. Patent No. 6,738,933. Washington, DC: U.S. Patent and Trademark Office.

Granger, K. (2013). Codeine phosphate/ramipril. Reactions, 1482, 16-14. Healey, F. (2016). Preventing falls in hospitals.

Healey, F., & Darowski, A. (2012). Older patients and falls in hospital. Clinical Risk, 18(5), 170-176.

Korać, D., & Simić, D. (2019). Fishbone model and universal authentication framework for evaluation of multifactor authentication in a mobile environment. Computers & Security, 85, 313-332.

Li, F., Harmer, P., & Fitzgerald, K. (2016). Implementing an evidence-based fall prevention intervention in community senior centers. American journal of public health, 106(11), 2026-2031.

Moody, D. L., & Shanks, G. G. (2003). Improving the quality of data models: empirical validation of a quality management framework. Information systems, 28(6), 619-650.

Nazarko, L. (2007). The impact of medication on falls. Nursing And Residential Care, 9(5), 208-211.

Ocker, S. A., Barton, S. A., Bollinger, N., Leaver, C. A., Harne-Britner, S., & Heuston, M. M. (2020). Preventing falls among behavioral health patients. AJN The American Journal of Nursing, 120(7), 61-68.

Oliver, D., Daly, F., Martin, F. C., & McMurdo, M. E. (2004). Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age and ageing, 33(2), 122-130.

Peerally, M. F., Carr, S., Waring, J., & Dixon-Woods, M. (2017). The problem with root cause analysis. BMJ quality & safety, 26(5), 417-422.

Perell, K. L., Nelson, A., Goldman, R. L., Luther, S. L., Prieto-Lewis, N., & Rubenstein, L. Z. (2001). Fall risk assessment measures: an analytic review. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 56(12), M761-M766.

Shorr, R. I., Griffin, M. R., Daugherty, J. R., & Ray, W. A. (1992). Opioid analgesics and the risk of hip fracture in the elderly: codeine and propoxyphene. Journal of Gerontology, 47(4), M111-M115.

Ward, R. E., Quach, L., Welch, S. A., Leveille, S. G., Leritz, E., & Bean, J. F. (2019). Interrelated neuromuscular and clinical risk factors that contribute to falls. The Journals of Gerontology: Series A, 74(9), 1526-1532.

Zanker, J., & Duque, G. (2020). Approaches for Falls Prevention in Hospitals and Nursing Home Settings. In Falls and Cognition in Older Persons (pp. 245-259). Springer, Cham.

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