Blog » Joint Commission Seeks to Prevent Patient Falls

Joint Commission Seeks to Prevent Patient Falls

Created Nov 18 2015, 07:00 PM by Lippincott Solutions
  • Fall prevention
  • long-term care
  • TJC
  • sentinel events
  • patient falls
  • post-acute care
  • LTC
  • The Joint Commission

Thursday, November 19, 2015
New alert outlines contributing factors and suggested solutions.

Patient falls are among the top 10 sentinel events reported to The Joint Commission Sentinel Event Database, with nearly two-thirds of those falls resulting in death. While most patient falls occurred in hospitals, a good number happened in other settings such as long-term care facilities. The alarming statistics prompted The Joint Commission to issue a Sentinel Event Alert recently.  The Joint Commission sends the alerts periodically to health care professionals, describing the common underlying causes of sentinel and adverse events with recommendations to reduce risk and prevent future occurrences.

Sentinel Events

Defining a sentinel event as a patient safety event that results in death, permanent harm or severe temporary harm, The Joint Commission seeks to educate and raise awareness among health care professionals with its periodic alerts. The patient safety events that are covered in the alerts are not primarily related to the natural course of the patient’s illness or condition.

In its Sentinel Event Alert: Issue 55, The Joint Commission stated that it had received 465 reports of patient falls with injuries since 2009, and that approximately 63 percent of those falls resulted in the patient’s death. The contributing factors included:

  • 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

Contributing factors 

Identifying contributing factors to patient falls as well as education, toolkits and research are among the suggested actions by The Joint Commission, as well as implementing the new Joint Commission Center for Transforming Healthcare’s Preventing Falls Targeted Solutions Tool®. The tool is a unique online application that guides an organization through a robust falls project by:

  • Measuring the current state
  • Analyzing and discovering causes
  • Implementing targeted solutions
  • Sustaining and spreading improvements

Executive vice president and chief medical officer of The Joint Commission, Ana Pujols McKee, MD says, “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.”

“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.”

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.

Founded in 1951, The Joint Commission accredits and certifies nearly 21,000 health care organizations and programs in the United States. The nonprofit organization seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.

Did you know that each year, 1 in 3 adults over age 65 falls, and that these occurrences are the leading cause of death and hospitalization for individuals in this age group?  

Check out a free demo of our Lippincott Professional Development Collection online course on Fall Prevention, which was co-developed with Joint Commission Resources (JCR) by clicking here:

And for additional information, click here to see a free sample of the Lippincott Procedures content on Fall Prevention.  

Are patient falls a concern for your facility? If so, what steps have your facility and its leadership taken to prevent their occurrence? What more do you think could be done?  Leave us a comment below!