Preventing falls and fall-related injuries in health care facilities.

* The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time. Published for Joint Commission accredited organizations and interested health care professionals, Sentinel Event Alert identifies specific types of sentinel and adverse events and high risk conditions, describes their common underlying causes, and recommends steps to reduce risk and prevent future occurrences. Accredited organizations should consider information in a Sentinel Event Alert when designing or redesigning processes and consider implementing relevant suggestions contained in the alert or reasonable alternatives. Please route this issue to appropriate staff within your organization. Sentinel Event Alert may only be reproduced in its entirety and credited to The Joint Commission. To receive by email, or to view past issues, visit www.jointcommission.org. Falls resulting in injury are a prevalent patient safety problem. Elderly and frail patients with fall risk factors are not the only ones who are vulnerable to falling in health care facilities. Any patient of any age or physical ability can be at risk for a fall due to physiological changes due to a medical condition, medications, surgery, procedures, or diagnostic testing that can leave them weakened or confused. Here are some statistics about falls in health care facilities: • Every year in the United States, hundreds of thousands of patients fall in hospitals, with 30-50 percent resulting in injury. 1-6 • Injured patients require additional treatment and sometimes prolonged hospital stays. In one study, a fall with injury added 6.3 days to the hospital stay. 7 • The average cost for a fall with injury is about $14,000. 8,9 Falls with serious injury are consistently among the Top 10 sentinel events reported to The Joint Commission's Sentinel Event database*, which has 465 reports of falls with injuries since 2009, with the majority of these falls occurring in hospitals. Approximately 63 percent of these falls resulted in death, while the remaining patients sustained injuries. In addition, ECRI Institute reports a significant number of falls occurring in non-hospital settings such as long-term care facilities. 10 Analysis of falls with injury in the Sentinel Event database reveals the most common contributing factors pertain to: • Inadequate assessment • Communication failures • Lack of adherence to protocols and …