Joint Commission Issues Alert on Falls in Hospitals

Megan Brooks

September 30, 2015

The Joint Commission (JC) wants healthcare facilities to pay more attention to falls and fall-related injuries and to implement proven prevention strategies.

Falls resulting in injury are a "prevalent patient safety problem," and not just among the elderly and frail, the JC notes in a Sentinel Event Alert issued September 28.

"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," the JC points out.

Each year, "hundreds of thousands" of patients fall in hospitals, resulting in injuries in up to half of cases — injuries that often require additional treatment and time spent in the hospital. The average cost for a fall with injury is about $14,000, the JC notes.

Falls with serious injury are consistently among the top 10 sentinel events reported to the JC's Sentinel Event database, and most of these falls happen in hospitals.

Take Action

"Preventing falls is difficult and complex," the JC acknowledges, but there is a "considerable" body of literature on how to reduce the risk for falls.

"Successful strategies include the use of a standardized assessment tool to identify fall and injury risk factors, assessing an individual patient's risks that may not have been captured through the tool, and interventions tailored to an individual patient's identified risks," they point out. "Historically, hospitals have tried to reduce falls — and to some extent have succeeded — but significant, sustained reduction has proven elusive," the JC says.

The alert encourages health facilities take the following actions to reduce falls and fall-related injuries:

  • lead an effort to raise awareness of the need to prevent falls resulting in injury;

  • establish an interdisciplinary falls injury prevention team or evaluate the existing one;

  • use a standardized, validated tool to identify risk factors for falls;

  • create an individualized care plan based on the identified risks, and implement preventive strategies;

  • standardize and apply practices and interventions known to be effective; and

  • perform postfall "huddles" to analyze the circumstances of a fall to guide improvement efforts.

Several organizations have fall-prevention tools and toolkits to help accomplish these goals, including, but not limited to, the Joint Commission, the Agency for Healthcare Research and Quality, the ECRI Institute, the Institute for Clinical Systems Improvement, and the Institute for Healthcare Improvement.

"Preventing Falls and Fall-Related Injuries in Health Care Facilities." JC. Published September 28, 2015. Full text


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