TJC Issues Sentinel Event Alert on Patient Falls

The Joint Commission has issued a new Sentinel Event Alert directed at patient falls. While similar alerts released by the agency have typically focused on falls in inpatient settings, this alert encompasses falls that happen in all types of healthcare facilities.

TJC’s Sentinel Event Alert #55 points out that “any patient of any age or physical ability can be at risk for a fall.” TJC’s Sentinel Event database includes 465 reported falls with injury since 2009 with approximately 63 percent of those resulting in death. Analysis of the falls with injury in the TJC database points to the following as common contributing factors:

• Inadequate assessment
• Communication failure
• 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

To learn more and to read TJC’s recommendations for preventing falls and fall-related injuries, click here.