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PSNet: Patient Safety Network
Sentinel Event Alerts

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

Sentinel Event Alert. September 28, 2015;(55):1-5.

Falls in the hospital are common, particularly among elderly patients, and falls resulting in serious injury or death are considered never events. This sentinel event alert identified 465 such cases reported to The Joint Commission since 2009 and acknowledges that preventing falls is difficult and complex. The Joint Commission recommends several strategies for preventing falls, including identifying patients at risk for falls, establishing a multidisciplinary fall prevention team, using patient-specific approaches to minimize fall risk, and conducting a post-fall multidisciplinary huddle to detect system flaws. These strategies have been successfully applied and shown to reduce falls in high-quality studies. The role of the physical environment as a risk for falls and the use of post-fall huddles are discussed in a recent AHRQ WebM&M commentary.