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Strategy Submission

Using a Fishbone (RCA) Diagram to Problem Solve Falls


Lori Rodriguez



Associate Professor



San Jose State University


Competency Categories:

Quality Improvement, Safety

Learner Level(s):

Pre-Licensure BSN, RN to BSN

Learner Setting(s):


Strategy Type:

Case Studies

Learning Objectives:

  • Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice
  • Use tools (such as flow charts, cause-effect diagrams) to make processes of care explicit
  • Participate appropriately in analyzing errors and designing system improvements

Strategy Overview:

This strategy is a participative exercise that gets students to
  • analyze a safety problem,
  • work with a fishbone diagram,
  • search out root causes,
  • identify limits of doing an RCA with limited input,
  • identify the importance and use of statistical data for making a case, and
  • identify one strategy that would impact the incidence of falls in this unit.
The story with directions

There has been a sharp increase in the number of falls on your unit. Last year there were 2 in a 1 year period. This year there have been 3 over the last 3 months. During this same time period there were several staff transfers out of your unit and the positions have not been filled due to a hiring freeze. You are dealing with what could be called chronic understaffing, staff working double shifts, and low morale. The float personnel who are sent to your unit have not been implementing the existing fall risk assessment protocol when they admit a patient. A spot check of your charts show that 50% of the patients on your unit have not had a standard fall risk assessment done on admission. When you go to find the tool or form that is used for the assessment you can find no forms.

Next, you look at the facts involving an individual patient who fell on your unit. Mrs. Nguyen is an 85 year old non English speaking patient who was admitted because of a transient ischemic attack and to rule out a stroke. She was in for observation and diagnostic testing. She got up to go to the bathroom. Since it was 2 a.m. apparently all the lights were out in the room. She tripped over a wheelchair that had been used earlier in the day to take her to interventional radiology.

Using the attached fishbone diagram, fill in the problem statement and the causes that you identify. Be prepared to discuss one impactful intervention that you would like to make to address the problem.

Discussion Questions:

  1. What contributory causes did you identify?
  2. Where did you place on the fishbone diagram such things as lack of staff, overworked staff, lighting conditions, the absence of a bed alarm, not following basic safety practices, the absence of fall risk assessments being done, the absence of fall risk assessment forms, the lack of availability of basic safety equipment (i.e. a walker), etc.
  3. Can all of the causes that you identified be placed somewhere on the fishbone diagram?
  4. Can you add other bones to the fishbone?
  5. Does it matter if a cause is shown in more than one area?
  6. If you were going to do an in-service to bring the attention of the staff to this problem, what data and information would you use and how would you display it?
  7. Would it be helpful to analyze the other two recent cases on your unit where the patients fell. Why or why not?
  8. Choose one intervention that might make an impact immediately and one long term
  9. Ensuing discussion on how the evidence shows that the prevention of falls requires a multipronged attack and a falls prevention program.

Submitted Materials:

113.Fishbone-diagram-for-QSEN-submission-WORKSHEET.docx -

Additional Materials:

Evaluation Description:

Having students turn in the fishbone with the problem statement and various identified causes meets the objectives listed. Additionally, the discussion that follows adds to their understanding of the process as well as the limits of having only one person try and figure out RCA’s.
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