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

2. 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.

3. Fox cerebri
hematoma

4. Hematoma
Fox cerebri and
right ventricule

5. Enoxaparine
40 mg/dayMorphine
and Pain-
Killers
Platelets:
76000
Fall hitting the
head

8. 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

9. 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

10. 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 .