Patient Safety Investigation Report

Prepared By: [Your Name]

Date: April 20, 2051

1. Introduction

Patient safety is a paramount concern in healthcare, where the goal is to provide safe and effective care. This report details the findings of an investigation into a recent patient safety incident at the facility. The purpose of the investigation is to identify the root causes of the incident, evaluate contributing factors, and recommend steps to prevent future occurrences.

2. Incident Overview

Date of Incident: April 15, 2051
Location: General Ward, Room 302
Patient Involved: Jane Doe
Staff Involved: Nurse Alice Johnson, Dr. Robert Smith

Brief Description of Incident:

On April 15, 2051, at approximately 10:15 AM, Jane Doe, a patient in Room 302 of the General Ward, experienced a fall while attempting to walk to the bathroom without assistance. Nurse Alice Johnson responded immediately, providing first aid, and Dr. Robert Smith was called to assess the patient. Minor bruising was observed, but no significant injuries were reported. The patient was stabilized and closely monitored for any delayed symptoms.

3. Investigation Process

3.1 Investigation Team

Lead Investigator: [Your Name], Risk Management Officer
Clinical Representative: Laura Miller, Nurse Supervisor
Quality Assurance Specialist: James Anderson, Safety Compliance Officer

3.2 Methods of Investigation

Data Collection: Medical records, patient reports, and incident logs were reviewed, along with surveillance footage from the hallway outside the patient's room.
Interviews: Key staff involved in the incident, including the attending nurse, physician, and patient, were interviewed to gather detailed accounts of the events leading to the incident.
Root Cause Analysis (RCA): A comprehensive RCA was conducted to identify the contributing factors and underlying causes of the incident, focusing on system failures, human factors, and environmental conditions.

4. Findings

4.1 Chronology of Events

10:00 AM: Nurse Alice Johnson administered the patient’s morning medications and checked on Jane Doe, who expressed feeling drowsy but stable.
10:15 AM: Jane Doe attempted to get out of bed and walk to the bathroom without using the call button for assistance. The patient lost balance and fell, landing on her side.
10:16 AM: Nurse Johnson responded immediately and helped the patient back into bed. Dr. Smith arrived shortly after to assess the situation.

4.2 Contributing Factors

Human Factors: The patient was not reminded to request assistance before attempting to walk. The attending nurse had noted the patient's slight drowsiness but did not anticipate the patient’s need to move without support.
System Failures: There was no visible signage or communication with staff highlighting the patient's fall risk. The patient’s mobility assessment had not been updated since the previous evening, despite changes in medication that could have impacted their stability.
Environmental Factors: The floor around the bed had recently been cleaned and was still slightly wet, increasing the risk of slips. No caution signage was placed to indicate the wet floor.

4.3 Root Cause

The root cause of the fall was a combination of insufficient communication between staff and patient about fall risks, along with the lack of a clear system to update and highlight changes in patient mobility status. The slippery floor further contributed to the incident.

5. Impact of the Incident

5.1 Patient Outcome

The patient sustained minor bruising but did not require further treatment beyond first aid and observation. They were kept under monitoring for an additional 24 hours but showed no signs of further complications.

5.2 Organizational Impact

The incident exposed weaknesses in the facility’s patient safety protocols, particularly in the areas of communication and environmental management. It has prompted a review of procedures and the implementation of changes to minimize future risks.

6. Recommendations

Based on the findings of the investigation, the following recommendations are provided to improve patient safety and prevent similar incidents:

Strengthen Communication Protocols: Staff should consistently remind patients of safety measures, especially after administering medication that may affect mobility. An automatic reminder system should be implemented during rounds for high-risk patients.
Fall Risk Indicators: Install color-coded wristbands and bedside signage for patients identified as fall risks. Update patient status immediately following changes in medication or medical conditions that affect mobility.
Environmental Safety Enhancements: Review and modify cleaning protocols to ensure that wet areas are properly marked, and the drying time is sufficient before patient movement is allowed. Additional caution signage should be used for recently cleaned areas.
Routine Reassessment of Patient Mobility: Ensure that mobility assessments are updated regularly, particularly after medication administration or surgery. This should be integrated into daily nursing rounds to ensure up-to-date information is communicated among staff.

7. Action Plan

Action Item	Responsible Party	Timeline	Status
Update communication protocols to include reminders for patients with mobility issues	Nursing Supervisor, Laura Miller	May 1, 2051	In Progress
Implement fall risk signage and wristbands for high-risk patients	Patient Safety Committee	May 15, 2051	Planned
Review and modify floor cleaning and safety procedures	Facilities Management	April 30, 2051	Completed
Add mobility reassessments to daily rounds	Nursing Department	Ongoing	Ongoing

8. Conclusion

The patient safety investigation has identified key areas for improvement in communication, environmental safety, and risk assessment. By adopting the recommended strategies, the facility can enhance patient safety and reduce the likelihood of similar incidents in the future. These improvements will contribute to creating a safer, more responsive healthcare environment that prioritizes patient welfare.