The objective was to identify how falls on psychiatric units occur, the underlying root causes and effective action plans to reduce falls and injuries.

A search of the Veterans Health Administration National Center for Patient Safety database was conducted to identify root cause analysis (RCA) reviews where a fall was sustained by a patient on a psychiatric unit. Seventy-five RCAs from January 2000 to March 2010 were included.

One hundred and thirty-eight actions were identified from the RCA reports. The most common activities the individual was engaged in during a fall included getting up from a bed, chair or wheelchair (21.3%); walking/running (10.7%); bathroom related (9.9%) or behavior related (9.9%). The most common root causes were environmental hazards (11.2%), poor communication of fall risk (8.9%), lack of suitable equipment (8.9%) and need for improvement of the current system for falls assessment (8.9%). Staff education (19.9%), development of tools to improve falls documentation (17.0%) and providing falls prevention equipment (14.2%) were the most frequent actions taken.

The results describe the location, activity and root causes surrounding falls that occur in psychiatric units resulting in injury, and provide some suggestions on how to implement a successful action plan.