Electronic Thesis and Dissertation Repository


Master of Arts




Alan Salmoni


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 and clear fall prevention strategy, risk assessment tool and fall data analysis methodology, and effective communication between the controllers were identified as potentially problematic. Suggestions were offered to improve these gaps.