TJC Sentinel Event Watch/Alert: Preventing falls and fall-related injuries in healthcare facilities

October 16, 2015    |   By: Calevir

Prevention of falls according to The Joint Commission can be a difficult and complex process. While falls resulting in death/serious injury are considered to be never events, since 2009 there have been 465 such cases reported.  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.  Strategies outlined for prevention of falls include the following: raise awareness; establish a multi-disciplinary fall prevention team; utilize standardized/validated tools for fall risk assessment; develop patient-specific care plans; standardize practices such as hand-off communication processes, conduct post-fall huddles and continually re-assess the patient. Also of interest is that an article was recently published noting that infections can be an underlying cause of falls.  Read the full article.

Read more on falls and fall prevention in Issue 55 of The Joint Commission Sentinel Event Alert:

For more resources on fall prevention please check out this PSNet page:


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