Falls Prevention – Best Practices

PUBLISHED: Mar 7, 2018
Relevant to: All Healthcare Organizations

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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