Preventing patient falls and fall-related injuries is the focus of the new Sentinel Event Alert: Issue 55 released recently by The Joint Commission. The new alert examines the contributing factors to patient falls and includes suggested solutions to be implemented by healthcare organizations to help reduce patient falls and falls with injury.
This topic was chosen for the Sentinel Event Alert because patient falls with serious injury are among the top 10 sentinel events reported to The Joint Commission Sentinel Event Database. The Joint Commission has received 465 reports of patient falls with injuries since 2009, and approximately 63% of those falls resulted in death.
The Joint Commission defines a sentinel event as a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in death, permanent harm or severe temporary harm where intervention is required to sustain life. Although the majority of falls reported to The Joint Commission occurred in hospitals, the ECRI Institute also reports a significant number of falls occurring in non-hospital settings such as long-term care facilities.
An analysis of falls with injury reported to The Joint Commission Sentinel Event Database from January 2009 through October 2014 showed the most common contributing factors include:
- Inadequate assessment,
- communication failures,
- lack of adherence to protocols and safety practices,
- inadequate staff orientation, supervision, staffing levels or skill mix,
- deficiencies in the physical environment, and
- lack of leadership.
The Sentinel Event Alert recommends the following six steps for reducing falls:
- Lead an effort to raise awareness of the need to prevent falls resulting in injury.
- Establish an interdisciplinary falls injury prevention team or evaluate the membership of the team in place to assure organizational infrastructure and capacity to reduce injury risk from falls.
- Use a standardized, validated tool to identify risk factors for falls.
- Develop an individualized plan of care based on identified fall and injury risks, and implement interventions specific to a patient, population or setting.
- Standardize and apply practices and interventions demonstrated to be effective.
- Conduct post-fall management, which includes: a post-fall huddle; a system of honest, transparent reporting; trending and analysis of falls which can inform improvement efforts; and reassess the patient.
The suggested actions in the Sentinel Event Alert address all of the identified contributing factors to patient falls. The Sentinel Event Alert is available online at http://www.jointcommission.org/assets/1/18/SEA_55.pdf.