Sentinel Event Alert aimed at preventing falls

Nurse Leader Insider, April 28, 2016

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Sentinel Event Alert aimed at preventing falls

Editor's note: Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, is a healthcare consultant in Trabuco Canyon, California, and a former Joint Commission surveyor. This originally appearead in the January issue of Briefing on Accreditation and Quality.

 The focus of The Joint Commission's most recent Sentinel Event Alert (SEA) is a challenge healthcare organizations have struggled with for years?preventing patient falls.

In late September, The Joint Commission released SEA #55, which focused on preventing falls and fall-related injuries in healthcare facilities. Patient falls with serious injuries are among the top 10 sentinel events reported to The Joint Commission Sentinel Event Database, according to a press release issued by the accreditor.

Patient falls remain a widespread and serious problem in healthcare facilities. The Agency for Healthcare Research and Quality (AHRQ) has estimated that 700,000?1 million people fall in healthcare facilities each year. As of March 2015, falls were the top category of root cause analyses submitted to the National Center for Patient Safety Patient Safety Information System, according to the U.S. Department of Veterans Affairs.

The consequences of a fall are often grave for patients and healthcare providers. Patient falls can lead to serious injuries, such as internal bleeding and fractures. In SEA #55, The Joint Commission states that 30%?50% of falls lead to injury. Approximately 63% of the 465 patient falls with injuries reported to The Joint Commission since 2009 have ended in death, according to The Joint Commission's press release.

As CMS no longer reimburses hospitals for care related to patient falls that have occurred in their own facilities, falls are also costly for healthcare organizations.

The Joint Commission Center for Transforming Healthcare Project has released an infographic on fall prevention that shows the high cost of a patient fall with an injury: an average of $14,056. Alternatively, the infographic states that fall reduction programs can help a 200-bed hospital save $1 million.


A complex problem

The Joint Commission identified the following as the most common factors contributing to falls, based on its analysis of falls with injuries in the Sentinel Event Database:

  • Lack of adequate assessment
  • Failure to communicate effectively
  • Inconsistent use of protocols and failure to follow pertinent safety practices
  • Staffing issues, including failure to provide adequate orientation for staff, lack of staff supervision, inappropriate skill mix, and low staffing levels
  •  Factors in the physical environment, such as loose handrails in corridors or slippery floors
  •  Leadership issues

Hospitals have made efforts to reduce falls, but as The Joint Commission notes in SEA #55, doing so is a complicated, challenging task. Healthcare organizations have to balance efforts to reduce falls with other competing demands, including standards that require hospitals to keep patients free from restraints.


Recommendations for reducing falls

Preventing falls involves commitment from healthcare leadership as well as a systematic, data-driven approach to reduce risks, The Joint Commission states in SEA #55. Additionally, it requires an interdisciplinary approach that calls for involvement from various stakeholders, including clinicians, technicians, leadership, risk management, facilities, pharmacy, IT staff, and environmental services.

The Joint Commission made several recommendations in SEA #55 to help healthcare organizations prevent falls and resultant injuries. To be successful in their efforts, it's critical for healthcare organizations to do the following:

  • Alert all staff members to the importance of fall prevention. It's important to communicate with staff members at all levels and across all departments about the safety principles that help to prevent falls. The Joint Commission also recommends using change management techniques to integrate these principles throughout patient care and education.
  • Involve team members from all disciplines in fall prevention. Because fall prevention requires an interdisciplinary approach, form a fall prevention team that includes a diverse group of participants, from clinicians to facilities staff. If an organization already has a fall prevention team, it should revisit the team's current membership and make sure all relevant stakeholders are represented.
  • Use the appropriate tools to pinpoint fall risk factors. The Joint Commission suggests using a standardized risk assessment tool, such as the Morse Fall Scale or the Hendrich II Fall Risk Model, preferably incorporated into the organization's electronic medical record. Additionally, the accreditor recommends performing an individualized risk assessment that ­includes the patient's age, gender, cognitive status, and level of function.
  • Provide a plan of care that is individualized to the patient. This plan should include identified risk for falls and injury, as applicable. The Joint Commission also suggests implementing interventions that are specific to the patient population or setting served.
  • Institute interventions that work. The Joint Commission recommends using practices that have been shown to be effective and can be standardized, including a standardized communication process for handoffs and individualized bedside education for patients.


Working to prevent falls is important, but how an organization responds after a fall occurs is also key. It's important to analyze why falls occur and identify opportunities for improvement.

After a fall, The Joint Commission suggests the following practices:

  • Hold a post-fall huddle as soon as possible, including staff at all levels as well as the patient, if possible. The huddle is a time to talk about what happened, why it occurred, whether the appropriate interventions were in place, how the patient's care plan will change, and how similar outcomes can be prevented. The Joint Commission also recommends using a standard post-fall huddle tool to ensure staff covers all of the critical information during these huddles.
  • Collect and analyze data for patterns and trends to identify factors that contributed to the fall. Identify opportunities for patient reassessment and ways to improve the fall prevention program.
  • Continually reevaluate patients who have fallen, identifying medication changes and alterations in their cognitive and functional status. The Joint Commission has found this key to preventing further falls.

More resources

There is a considerable amount of research on falls prevention and several tools and resources available for healthcare organizations to reduce patient falls. Some of these resources include:

  • The AHRQ's Preventing Falls in Hospitals, a toolkit that provides information about developing, implementing, and sustaining a fall reduction program.
  • The U.S. Department of Veterans Affairs National Center for Patient Safety's Falls Toolkit, a comprehensive guide that includes background information, guidance on developing a falls prevention team and falls prevention policy, interventions to reduce risk of falls and resultant injuries, and a post-fall huddle tool.
  • The Institute for Clinical Systems Improvement Prevention of Falls (Acute Care) protocol, which recommends risk assessments for falls, as well as guidance on how to communicate risk factors and perform interventions.
  • The Institute for Healthcare Improvement's Transforming Care at the Bedside How-To Guide: Reducing Patient Injuries From Falls, which provides guidance on how to identify patients at greatest risk of becoming seriously injured from falls and implement interventions to prevent or minimize injuries.


Agency for Healthcare Research and Quality. (2013). Preventing falls in hospitals.

Degelau, J., Belz, M., Bungum, L., Flavin, P. L., Harper, C., Leys, K., ... Webb, B. (2012). Prevention of falls (acute care). Institute for Clinical Systems Improvement.

Institute for Healthcare Improvement. Transforming care at the bedside how-to guide: Reducing patient injuries from falls.

The Joint Commission. (2015). Preventing falls and fall-related injuries in health care facilities. Sentinel Event Alert 55.

The Joint Commission Center for Transforming Healthcare Project. Preventing falls infographic.

U.S. Department of Veterans Affairs National Center for Patient Safety. Falls toolkit.

Zhani, E. E. (2015, September 28). New Sentinel Event Alert focuses on preventing falls.

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