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Most (n = 15; 68%) involved patient falls from the <jats:styled-content style=\"fixed-case\">OR<\/jats:styled-content> bed. Other patient falls (n = 6; 27%) occurred when the patient was transferred to or from the <jats:styled-content style=\"fixed-case\">OR<\/jats:styled-content> bed, and one fall (5%) occurred at another time. Root causes of the falls included tilting of the <jats:styled-content style=\"fixed-case\">OR<\/jats:styled-content> bed, issues with safety restraints, malfunctioning <jats:styled-content style=\"fixed-case\">OR<\/jats:styled-content> bed or gurney locks, inadequate patient sedation, and poor communication among team members. One fall (5%) resulted in a major injury, four falls (18%) resulted in minor injuries, six falls resulted in no injury, and 11 falls (50%) had no reported outcome. Falls in the <jats:styled-content style=\"fixed-case\">OR<\/jats:styled-content>, although rare, can be injurious. We drafted recommendations based on the root causes that include specific guidance on communication, teamwork, best practices, restraints and equipment, and training.<\/jats:p>","DOI":"10.1002\/aorn.12372","type":"journal-article","created":{"date-parts":[[2018,9,28]],"date-time":"2018-09-28T22:48:38Z","timestamp":1538174918000},"page":"386-397","update-policy":"http:\/\/dx.doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":11,"title":["Root Cause Analysis of Reported Patient Falls in <scp>OR<\/scp>s in the Veterans Health Administration"],"prefix":"10.1002","volume":"108","author":[{"given":"Christina M.","family":"Soncrant","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lisa J.","family":"Warner","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Julia","family":"Neily","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Douglas E.","family":"Paull","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lisa","family":"Mazzia","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Peter D.","family":"Mills","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"William","family":"Gunnar","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robin R.","family":"Hemphill","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2018,9,28]]},"reference":[{"key":"e_1_2_10_2_1","unstructured":"List of SREs. 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