Medicine and Health Sciences Commons^™

Describing The Falls Prevention Program At An Acute Care Hospital In Ontario Using Leveson’S Systems Model, Mahboubeh Mehrjoo

Electronic Thesis and Dissertation Repository

Falls are the most frequent adverse event in acute care hospitals. Although a large number of studies have addressed the patients’ risk factors for falls and best practices in fall prevention, patients falls still remain a major problem. This study applied a systemic methodology (Causal Analysis based on STAMP (CAST)) to depict Ontario’s acute care hospital structure related to patient fall prevention. The system’s component behaviours and interactions were described and deficits and inappropriate control mechanisms among the system’s controllers were identified. As a result of the CAST analysis, the complexity of the health care system, lack of a consistent …