Application of Root Cause Analysis in Improving Care for Falls Associated With Cough Syncope.

Cough syncope, an infrequent condition causing sudden transient unconsciousness from coughing, elevates hospitalized patients' fall risk with severe complications. A 59-year-old male admitted for pneumonia and suspected cough syncope fell post-cough in the restroom, resulting in subarachnoid hemorrhage. Root cause analysis revealed that there are systemic gaps in clinical nursing: lack of targeted nursing protocols, training, educational materials, poor medical and nursing staff communication, and suboptimal environment. Interventions included developing nursing guidelines, enhancing staff training, creating multi-format health education, optimizing interdisciplinary communication via a mobile system, and improving environmental safety. Subsequent 22 patients had no falls, with 100% nurse competency and reduced hospitalization duration. This highlights the value of root cause analysis in mitigating fall risks for such patients, while multi-center research and long-term follow-up are needed.