Patient Falls in Missouri – Addressing Toolkits

December 20, 2015    |   By: Calevir

Falls in Missouri Report CoverDespite a multitude of toolkits and resources, patient falls remain a prevalent safety issue. Over the past three years, falls have consistently been in The Joint Commission’s top ten reported sentinel events. In 2013 falls were the fifth most commonly reported sentinel event, rising to the second most reported event in 2014. Currently falls are the fourth most reported sentinel event through 3rd quarter of 2015.1 This is concerning in two regards: 1. Increased avoidable injury to patients, 2. Financial risk for the facility due to increased length of stay and cost of treating the fall injury.

The Missouri Hospital Association and the Center for Patient Safety (CPS) began a collaborative effort the summer of 2015 to review claims data and patient safety event data to see if Missouri was following the national landscape trend of an increasing number of falls. The time frame reviewed was October 1, 2013 through March 31, 2015. By correlating the data collected by each organization, it was hoped that a trend could be identified; and that by analyzing causal/contributing factors, there could be lessons learned in regards to falls in the state of Missouri and how to prevent them from occurring in a healthcare facility.

SEA TableAs this collaborative effort was going forth, The Joint Commission issued Sentinel Alert Event #55 on September 28, 2015.2 This alert highlighted the fact that fall prevention is a complicated process involving many moving parts.

The Missouri Hospital Association utilized HIDI Analytics claims data pertaining to falls and trauma-related harm in the state of Missouri for the time frame noted above, while CPS analyzed falls submitted to the PSO. As the Sentinel Event noted an increase in the number of falls reported as sentinel events, Missouri also noted an increasing trend in falls. Download the full report in collaboration with the Missouri Hospital Association.


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The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.