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Patient Falls Top TJC’s 2Q 2016 List of Reported Sentinel Events

Patient Falls Top TJC’s 2Q 2016 List of Reported Sentinel Events

The statistics on patient falls are not encouraging:

  • Between 700,000 and 1,000,000 people experience falls in US Hospitals annually.
  • 30 to 50% of those falls result in injury
  • Falls cause prolonged hospital stays and increased costs

According to The Joint Commission, through the 2Q of 2016, sentinel event reports of falls are significant.  Root cause analysis has shown that factors that contribute to a patient fall include:

  • Inadequate assessment
  • Communication failures
  • Lack of adherence to protocols and safety practices
  • Inadequate staff orientation, supervision and staffing levels
  • Physical environment deficiencies

Patient falls are not inevitable. Research shows that close to one-third of falls can be prevented. Creating a fall-prevention culture, consistently reminding staff, patients and families of strategies to prevent falls and using standardized fall risk assessment tools are all methods hospitals have successfully used to decrease the number of patient falls within their organizations.

Specific best practices in fall prevention include:

  • Initiating an ongoing awareness campaign that increases knowledge among staff, patients and families of the need to prevent falls and simple steps that can aid in fall prevention.
  • Developing and implementing a organization-wide process for creating individualized plans of care that uses standardized and validated fall risk assessment tools such as the More Fall Scale or the Hendrich II Fall Risk Model.
  • Standardizing, implementing and providing on-going training for practices that have demonstrated effectiveness in fall prevention:
  • Hand-off communication processes that convey patient risk for falls.
  • One-to-one education of each patient at the bedside.
  • Conducting post-fall management analysis that incorporates a system of honest, transparent reporting, involves staff from all levels and, if possible, the patient, and reviews if appropriate interventions are in place, why the fall may have occurred and strategies for preventing future falls.

Here are some resources your healthcare organization may want to take a look at:

AHRQ – Preventing Falls in Hospitals:  A Toolkit to Improving Quality of Care

IHI – Transforming Care at the Bedside How-to-Guide:  Reducing Patient Injuries from Falls

CMS – Hospital Engagement Networks

AHA – Hospital Engagement Network 2.0


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