Fall Prevention: Introduction to Root Cause Analysis

Root cause analysis (RCA) is a process used to identify the primary source or cause(s) of a problem. With respect to fall prevention in long term care settings, (RCA) is a systematic process for identifying the root cause (s) of resident falls. RCA is based on the idea that effective fall prevention requires more than merely ‘putting out fires’ or concentrating on injuries and life-threatening conditions but finding a way to prevent falls from occurring. This course will help long-term care staff understand RCA and how it can help pinpoint contributing factors to the problem of falling.

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Upon completion of this course participants will be able to:

  1. Explain the reasons for RCA.
  2. Recall the benefits of RCA.
  3. Recall the key concepts that support RCA.
  4. List the ‘5 Whys’ RCA method.
  5. Describe the RCA processes.


Chapter 1: Introduction to Root Cause Analysis (RCA)

  • About this course
  • Objectives

Chapter 2: Fall Prevention 101

  • Fall Risk Factors
  • Repeat Fall Risk Factors
  • Fall Prevention Interventions
  • Post Fall

Chapter 3: What Is Root Cause Analysis?

  • Types of RCA

Chapter 4: Individual-Level RCA

  • 5 Whys Analysis
  • Common Root Causes

Chapter 5: The RCA Process

  • Step 1: Assemble the Team
  • Step 2: Gather the Facts
  • Step 3: Identify Root Causes
  • Step 4: Develop a Risk Reduction Plan
  • Step 5: Evaluate Effectiveness of Actions

Chapter 6: Process and Organizational Issues

  • Care Process or Staff Factors
  • Organizational Factors
  • RCA Process

Chapter 7: Plan-Do-Study-Act (PDSA) Cycle

  • Plan
  • Do
  • Study
  • Act

Chapter 8: RCA Tools

  • Brainstorming
  • Flowcharting
  • Fishbone Diagrams
  • Affinity Diagrams
  • Summary
  • References
  • California Bill 241
  • Implicit Bias in Healthcare
  • What is Implicit Bias?
  • Implications of Implicit Bias in Healthcare
  • How to Reduce Implicit Bias

Price: $10.00

Contact Hour: 1

Course Author

Rein Tideiksaar

Rein Tideiksaar, PhD, PA-C, or Dr. Rein as he is commonly referred to, is the president of Fall Prevent, LLC, Blackwood, New Jersey, a consulting company that provides educational, legal, and marketing services related to fall prevention in the elderly.

Dr. Tideiksaar is a gerontologist, which is a health care professional who specializes in working with elderly patients, and a geriatric physician's assistant. He has been active in the area of fall prevention for over thirty years. 

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