​Noting that falls are consistently among the top 10 reported sentinel events, and that elderly patients and those with identified risk factors are not the only patients who may fall in healthcare facilities, the Joint Commission has issued its latest Sentinel Event Alert highlighting strategies to raise awareness and limit the incidence of falls. Citing resources and references that include the HRC guidance article Falls, the Joint Commission recommends that organizations begin by raising awareness of falls throughout the organization and establish an interdisciplinary falls prevention committee. Providers should use individualized, validated assessment tools to identify patients' risk factors and develop individualized care plans based on those risks that are specific to patients, populations, or care settings. Standardized interventions, including standardized handoff communication and one-to-one patient education, should also be in place, the Joint Commission says. When falls do occur, the agency recommends a post-fall huddle to discuss factors such as what happened, how it happened, and why; report, aggregate, and analyze information related to falls; and continue to reassess the patient. The Alert also includes a list of falls-related Joint Commission accreditation standards for the hospital, ambulatory, home care, and nursing care programs.

HRC Recommends: Falls are a high-volume, high-risk, high-cost challenge for healthcare facilities. Risk managers should ensure that their facilities implement falls prevention programs and monitor progress in reducing the frequency and severity of patient falls. To reduce falls rates, facilities must have a process to assess an individual's risk for falling and have targeted interventions to reduce a person's risk of falling. Facilities must also review occurrences of falls with the goal of identifying and addressing causal and contributing factors. This work is performed by an interdisciplinary team of practitioners and administrators who work toward a unified goal of reducing falls within the institution.