Careful identification, investigation, and analysis of patient safety events, as well as strong corrective actions that provide effective and sustained system improvement, is essential to reduce risk and prevent patient harm. The Joint Commission partners with healthcare organizations with the use of the Sentinel Event Policy which focuses on opportunities for change, systems improvement, increased resilience of the organization, maintaining the confidence of the public, clinicians, and the healthcare organization along with preventing further harm when a serious patient safety event has occurred. A Sentinel Event has been identified as a patient safety event that reaches a patient and results in any of the following: death, permanent harm, and/or severe temporary harm and intervention required to sustain life. (CAMH, 2022).
Falls are consistently listed as one of The Joint Commission’s “Top 10” Sentinel Events reported to the database, with patient falls being the single largest reported harm in 2021. While extensive clinical research and adult evidence-based strategies in fall prevention exist, reducing injurious falls in the hospital environment remains difficult. Among adults 65 years or older within Washington and Oregon, falls are the leading cause of injury-related death for persons both in and out of the hospital per 100,000 people. Moreover, men are 25.5% more likely to die from a fatal fall than women in Washington State. If you cross over into Oregon, this age-adjusted death rate climbs to 36% for men over their female counterparts.
Washington State Hospital Association, member hospitals from Washington and Oregon, regional fall coalitions and the WA DOH remain committed and passionate about fall prevention and reducing harm secondary to falls. This continued passion for fall prevention work is guided by key stakeholders throughout WA state dedicated to providing evidence-based strategies that include patient/family engagement and community-based programs, along with the utilization of data to better understand our vulnerable populations and to target key issues surrounding fall prevention. As part of this dedication to fall prevention, WSHA has and leads an interdisciplinary collaborative known as the WSHA Falls with Injury Prevention Collaborative (FIPP).
Falls with Injury Prevention Collaborative (FIPP)
The WSHA Patient Safety and Quality Team created this collaborative forum in early 2021. The purpose of the FIPP is to:
- Guide hospitals convene collective partners, and leaders in this space to share, spread successful implementation strategies to reduce fall with injury related harm.
- Provide clinical and best practice expertise, consultation, and advocacy in fall prevention.
- Engage and empower hospitals with stratifying facility-centric vulnerabilities within the data that informs and supports equitable approaches in reducing patient harm.
For more information regarding the FIPP and/or how to join, please contact Amy Anderson
Toolkits & Resources
Post Fall Management
Post Fall Management is essential to maintaining a patient’s safety, as well as an opportunity for a healthcare facility to identify key learnings about how to prevent future falls. The definition of a post fall huddle (PFH) may vary in journal articles, but in general, “a huddle is an immediate evaluation of each fall by a team—preferably an interprofessional one—with the patient in the environment in which they fell (Quigley, 2019)”. Patients and family support the clinical team in identifying immediate opportunity to prevent a recurrent fall. Utilizing an interdisciplinary team-based approach to learning, staff that participate in PFH are more likely to have positive perceptions of teamwork in addition to supporting efforts regarding fall-risk reduction and supporting a patient safety culture. Additionally, when senior leadership partner in implementing resources and provide support, staff may perceive that the organization is committed to learning from each fall and to continuously decreasing the risk of patient falls across the system (Jones, et.al., 2019).
WSHA has developed evidence-based tools to support Post Fall Management. The Post Fall Huddle Tool supports hospital staff, patients, and their family in a safe learning environment to understand why a fall occurred, determine the risk factors that caused the fall and to assess patient injury. Additionally, the WSHA Post Fall Audit Tool evaluates the effectiveness of the Post Fall Huddle and provides hospital leadership feedback on the effectiveness and reliability of the process as well as opportunities to
QBS Falls Form 2022 Updated 1/18/2023