CHA News Article

New Sentinel Alert Focuses on Preventing Patient Falls

The Joint Commission yesterday released a Sentinel Event Alert examining the contributing factors to patient falls and offering suggested solutions health care organizations can implement to help reduce them. 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. Analyzing the falls with injury reported to its sentinel event database from January 2009 through October 2014, The Joint Commission found the most common contributing factors include: 

  • 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

The suggested actions in the Sentinel Event Alert address all of the identified contributing factors to patient falls. The alert also includes links to toolkits and research on falls prevention, and it introduces The Joint Commission Center for Transforming Healthcare’s Preventing Falls Targeted Solutions Tool.