Analysis of Near Miss and Sentinel Incidents in Elderly Fall Accidents: Using the Korean Patient Safety Reporting Learning System data(2020∼2022)

Objective: This study aimed to determine the degree of harm and related factors of fall accidents in Korea. Method: This study performed a cross-sectional analysis of secondary research study based on data from the Korean Patient Safety Reporting and Learning System and analyzed 13,292 people aged 60 years or older from 2020 to 2022 by using chi-square test and multinomial logistic regression analysis. Results: The factors associated with the occurrence of near misses compared to adverse incidents were significantly higher in rehabilitation and physical therapy departments(OR=3.18, 95% CI=2.35∼4.29, p<.001), neurology and neurosurgery departments(OR=1.61, 95% CI=1.41∼1.84, p<.001), and advance general hospitals(OR=3.80, 95% CI= 2.53∼3.62, p<.001). Factors related to the occurrence of sentinel incidents compared to adverse incidents were higher in rehabilitation and physical therapy departments(OR=2.90, 95% CI=1.944.33, p<.001), outpatient, examination, injection and treatment rooms(OR=2.46, 95% CI=2.06∼2.95, p<.001) were lower in general hospitals compared to nursing homes(OR=0.42, 95% CI=0.37~0.49, p<.001). Conclusion: In order to reduce and prevent falls accidents in the elderly, voluntary reporting of near misses, adverse incidents and sentinel incidents, sharing of information about them, and differentiated fall interventions according to the degree of harm from falls are necessary.