A broader focus on falls inside and outside the hospital

Patient Safety Monitor Insider

December 9, 2015

For the last decade, patient falls have been a consistent source of frustration for healthcare providers and regulators alike. Perhaps it's that frustration boiling over that led The Joint Commission to release a Sentinel Event Alert in September targeting "falls and fall-related injuries in healthcare."

Since hospitals began reporting sentinel events to The Joint Commission in 2004, patient falls have been among the top 10 sentinel events reported to the accreditation agency. Updated sentinel event data released in August indicated that patient falls ranked sixth among reported sentinel events from 2004 through the second quarter of 2015, with 750 falls in that time frame. Through the first half of this year, 39 falls have been voluntarily reported to The Joint Commission.

Sentinel events track serious patient safety incidents, such as falls, that result in "death, permanent harm, or severe temporary harm where intervention is required to sustain life." According to Sentinel Event Alert 55, providers have reported 465 falls with injury since 2009. Nearly two-thirds of those resulted in death.

In light of these statistics, the Sentinel Event Alert outlines six actions to prevent falls, including specific interventions to reduce falls that result in injury. That distinction is key, says Pat Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP, associate chief of nursing service for research and associate director of the VISN 8 Patient Safety Center of Inquiry at the James A. Haley Veteran's Affairs Medical Center in Tampa, Florida. Quigley's organization provided input for the Sentinel Event Alert, urging The Joint Commission to target falls that result in injury. Providers cannot prevent all falls, but targeting those falls that could lead to serious injury or death can significantly improve patient safety.

Continue reading this article on the Patient Safety Monitor website. Subscribers have free access to this article in the December issue.