Joint Commission Issues Sentinel Event Alert on Patient Falls

This is not the first alert directed at falls, which are described as a "complex, chronic problem." The alert is directed at healthcare facilities in general, not only inpatient settings.

Despite widespread prevention efforts, patient falls remain a dogged and dangerous problem in healthcare settings, The Joint Commission says.

In a Sentinel Event Alert issued last week, The Joint Commission noted that patient falls with serious injury are among the top 10 sentinel events reported to its database, which has received 465 reports of patient falls with injuries since 2009. Of those falls, 63% resulted in death.

Erin DuPree, the Chief Medical Officer and Vice President for The Joint Commission Center for Transforming Healthcare says that this latest sentinel alert is not the first directed at falls, which have proved vexing for many providers.

"It's a complex, chronic problem and with the complexity of healthcare organizations today it is why we are still dealing with falls," she says.

"Ultimately, a lot of the falls work has been around identifying who is at risk and who are the high-risk patients. Really, especially in the hospital setting or any healthcare setting, all patients are at risk at some level. It's a different approach when you look at it from that lens."

The Joint Commission defines a sentinel event as a patient safety event not primarily related to the natural course of the patient's illness or underlying condition that reaches a patient and results in death, permanent harm, or severe temporary harm where intervention is required to sustain life.

Although the majority of falls reported to The Joint Commission occurred in hospitals, the ECRI Institute also reports a significant number of falls occurring in non-hospital settings such as long-term care facilities. 

"This alert is about healthcare facilities in general," DuPree says. "A lot of the understanding around falls has come from the inpatient setting, but this alert is targeted to healthcare facilities in general."

The sentinel event alert cites these common contributing factors for falls:

• 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

DuPree says provider leaders have to ask themselves some tough questions about fall prevention strategies in their organizations.

"The first things leaders need to ask themselves is are they just trying to meet compliance with CMS or are they committed to preventing falls in their organizations, which would require them to understand their outcomes and their aims."

"Are they really aiming to prevent falls for every single patient? Then, look at how other staff and management teams are approaching the problem. Are they approaching it in a systematic, data-driven way? Are they using robust process improvement, or are they just throwing every solution set at the wall and hoping it works?"

DuPree says consistency across the entire organization is also a challenge.

"Everyone says 'oh yeah we have a falls risk assessment. We put that in our EMR,'" she says. "But when they drill down in a systematic data-driven way, they find that it's not implemented consistently or well. Every nurse has their own definition of what different aspects of the assessment mean and maybe it's not built into their orientation and so the new nurses don't even know and they learn through osmosis. So, the implementation and delivery of these preventive measures are done inconsistently."

DuPree says it is also important that every healthcare organization understand its own specific challenges and not rely on a one-size-fits-all approach.

"It's very important that they discover what their issues are to target solutions to their unique needs. That is at the heart of these tough, chronic issues in healthcare today," she says. "The approach to improvement is usually far too basic for the complexity of these problems. That is what we find in healthcare today. One size does not fit all, but that is the approach used by a majority of healthcare organizations today. We will not improve or transform in healthcare using that approach."