New Sentinel Event Alert Focuses on Preventing Patient Falls

Source: The Joint Commission (website)
By: Elizabeth Eaken Zhani, Media Relations Manager, 
September 28, 2015
(OAKBROOK TERRACE, Illinois – September 28, 2015) Preventing patient falls and fall-related injuries is the focus of the new Sentinel Event Alert: Issue 55 released today by The Joint Commission. The new alert examines the contributing factors to patient falls and includes suggested solutions to be implemented by health care organizations to help reduce patient falls and falls with injury.
This topic was chosen for 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 percent 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
  • Lack of leadership
The suggested actions in the Sentinel Event Alert address all of the identified contributing factors to patient falls. Listed resources in the alert include links to toolkits and research on falls prevention, and it introduces the Joint Commission Center for Transforming Healthcare’s Preventing Falls Targeted Solutions Tool®.
“Fall prevention is the responsibility of everyone in the organization and success is highly dependent on leadership playing a primary role. It is their commitment and approach that determines an organization’s ability to significantly reduce and sustain the reduction in falls,” said Ana Pujols McKee, MD, executive vice president and chief medical officer, The Joint Commission. “There are several proactive steps in the Sentinel Event Alert that leaders can initiate such as educating and raising awareness of the need to prevent falls resulting in injury, ensuring the implementation of a validated tool to identify the risk factors for falls, and establishing an interdisciplinary falls injury prevention team.”
Sentinel Event Alert is published periodically by The Joint Commission for health care professionals. It describes the common underlying causes of sentinel and adverse events and recommends steps to reduce risk and prevent future occurrences. Sentinel Event Alert topics are determined by the Joint Commission’s Patient Safety Advisory Group comprised of external members with significant expertise in health care and patient safety, and presided over by Ana Pujols McKee, MD, executive vice president and chief medical officer, The Joint Commission.
For more information about the sentinel event statistics and previous issues of Sentinel Event Alert, please visit The Joint Commission’s Sentinel Event Alert Web page.