Abstract
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.