Fall Investigation Root Cause Analysis

Structured inspection template for investigating a fall with major injury, documenting the event sequence, system factors, contributing conditions, and corrective actions to prevent recurrence.

Incident Overview

• Date and time of fall documented
• Location of fall documented with specific area
• Injury severity classified and major injury confirmed
• Immediate medical response initiated
• Witnesses identified and interviewed

Event Sequence and Timeline

• Pre-fall activity documented
• Timeline includes last known safe condition and discovery time
• Contributing events immediately before the fall identified
• Post-fall assessment and notifications completed

Environmental and Equipment Factors

• Floor surface free of slip, trip, and spill hazards
• Lighting adequate for safe movement in the area
• Assistive device inspected and found in serviceable condition
• Bed, chair, wheelchair, or other equipment positioned safely
• Call light or alarm device accessible within reach

Human Factors and Supervision

• Required supervision or assistance was provided
• Fall risk status and precautions were current and communicated
• Staffing level and workload were adequate at the time of the event
• Communication breakdowns identified

Root Cause Analysis and Corrective Actions

• Primary root cause identified
• Contributing system factors identified
• Corrective actions assigned with owner and due date
• Follow-up monitoring plan defined