The Joint Commission (TJC) published, Preventing falls and fall-related injuries in health care facilities, a new Sentinel Alert #55 on September 28, 2015 at http://www.jointcommission.org/assets/1/18/SEA_55.pdf

What’s the problem? Falls with serious injuries are among the top 10 events reported to TJC.   Analysis of that data shows that contributing factors are related to:

• 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 (page 1)

What to do?   Here are TJC recommendations

1. Raise awareness of falls resulting in injury
2. Establish an interprofessional falls committee
3. Use a reliable, valid risk assessment tool
4. Use EBP
   1. Standardized handoff including risk for falls
   2. One-to-one, bedside education of patients (& families?)
5. Conduct post-fall management, which includes: a post-fall huddle; a system of honest, transparent reporting; trending and analysis of falls which can inform improvement efforts; and reassess the patient (page 2)

Critical thinking:  How would you apply AHRQ toolkit: Preventing Falls in Hospitals to your unit.

Want more info?   For tools, resources, & more details on above, see Joint Commission (2015, September 28). Preventing falls and fall-related injuries in health care facilities, Sentinel Event Alert, Issue 55.  Retrieved from Joint http://www.jointcommission.org/assets/1/18/SEA_55.pdf