Stay Alert: The Joint Commission Issues Sentinel Event Alert on Patient Falls

Although falls are often associated with elderly and frail patients, the Alert notes that any patient can be at risk for a fall, regardless of age or physical ability. Physiological changes due to a medical condition, medications, surgery, procedures, or diagnostic testing can contribute to patient weakness or confusion and lead to a fall.  

TJC identified  the most common factors contributing to falls that resulted in injury: 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.  Although hospitals and other facilities have taken steps to reduce falls with some level of success, a consistent and notable reduction has not emerged. Indeed, TJC pointed out that “falls with serious injury are consistently among the Top 10 sentinel events reported to the [TJC] Sentinel Event database … .”

In the Alert, TJC recommended several actions to assist health care organizations in preventing falls and injuries resulting from falls, including:

• Raising awareness of the need to prevent falls that result in injury. This includes communicating safety information to staff at every level and incorporating safety precautions into the full continuum of patient care and education.

• Establishing an interdisciplinary falls injury prevention team (or evaluating the membership of the current team) to assure organizational infrastructure and capacity to reduce injury risk from falls.

• Using a standard, validated tool to identify risk factors for falls, preferably integrated into the electronic medical record. Patient assessments for falls should be comprehensive and individualized and include key elements. Staff should be appropriately trained to ensure they are rating patient risk in a consistent manner.

• Developing an individualized plan of care based on identified fall and injury risks. Implementation of interventions should be specific to a patient, population, or setting.

• Standardizing and applying practices that have been demonstrated to be effective. This includes a standardized hand-off communication process for relaying patient risk of falls to other caregivers. Also, one-to-one education of each patient at the bedside regarding strategies to reduce falls is recommended.

• Finally, TJC recommended conducting post-fall management, including, among other things, a post-fall huddle as soon as possible after a fall; a system of transparent reporting; trending and analysis of falls; and reassessing the patient on a continuing basis.

TJC also identifies several tools and guides from various resources available to help facilities reduce fall incidents.

Although the Sentinel Event Alert does not change existing standards or initiate new ones, TJC-accredited health care facilities would be wise to review TJC’s recommendations carefully and determine whether they should implement them. Alerts provide insight into those topics that TJC believes significantly impact patient care, so along with potentially providing a patient care benefit, the Alerts may inform facilities as to where TJC will focus its attention in future surveys or standard revisions.