Falls Prevention – Best Practices
The Joint Commission recently released their 2017 Sentinel Event statistics and falls were the second most-often reported Sentinel Event last year. In 2017 organizations self-reported one hundred fourteen (114) Sentinel Events related to falls, an increase from 2016 when there one hundred two (102) reports. Falls resulting in patient injury are a significant patient safety issue and have been towards the top of TJC’s most-reported Sentinel Event list for years.
In 2015 TJC issued a Sentinel Event Alert that addressed falls prevention in health care facilities. TJC identified several root causes that contribute to patient falls including:
- 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 release of the TJC 2017 Sentinel Event statistics provides a great opportunity for organizations to review their falls prevention strategies. Best practices for falls prevention include:
- Incorporating the concept of fall prevention into the organization's culture
- Talk about falls prevention!
- Initiate an awareness campaign to increase knowledge of the need to prevent falls resulting in injury.
- Establishing an interdisciplinary falls injury prevention team
- How often does the team meet?
- What disciplines are represented on the team?
- How are recommendations from the team incorporated into day-to-day operations?
- Adopt and implement a standardized, validated tool such as the More Fall Scale or the Hendrich II Fall Risk Model to identify risk factors for falls.
- Standardize and implement practices that have demonstrated effectiveness including:
- Implementing individualized care plans for patients that identify falls risk and implement patient-specific interventions.
- Ensure that hand-off communication processes convey patient risk for falls.
- Provide one-to-one education at the bedside for patients at risk for falls.
- Adopt a “post-fall” management program that is not punitive but rather focuses on why a fall may have occurred and identifies strategies for preventing future falls.
- Allow for honest, transparent reporting of falls.
- Involves staff from all levels.
- Include the patient when appropriate.
Included with today’s notice are several example policies that address falls prevention.
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