Patient Falls in Seclusion Rooms in Psychiatric Inpatient Care: A Sociotechnical Probabilistic Risk Modeling Study

Background: Patient falls are a major adverse event in psychiatric inpatient care. Purpose: To model the risk for patient falls in seclusion rooms in psychiatric inpatient care. Methods: Sociotechnical probabilistic risk assessment (ST-PRA) was used to model the risk for falls. Data sources were the research team, literature review, and exploration groups of psychiatric nurses. Data were analyzed with fault tree analysis. Results: The risk for a patient fall in a seclusion room was 1.8%. Critical paths included diagnosis of a psychiatric disorder, the mechanism of falls, failure to assess and prevent falls, and psychological or physical reason. The most significant individual risk factor for falls was diagnosis of schizophrenia. Conclusions: Falls that occur in seclusion events are associated with physical and psychological risk factors.