Effective Jan. 1, 2021: Sentinel Event Policy to define fall events
Beginning Jan. 1, 2021, The Joint Commission will start including a definition for fall events in its Sentinel Event Policy. This is being done to help staff in all health care settings to be able to understand whether a fall should be reviewed as a sentinel event. It will state:
Fall event – Fall resulting in any of the following: any fracture; surgery, casting, or traction; required consult/management or comfort care for a neurological (for example, skull fracture, subdural or intracranial hemorrhage) or internal (for example, rib fracture, small liver laceration) injury; or a patient with coagulopathy who receives blood products as a result of the fall; death or permanent harm as a result of injuries sustained from the fall (not from physiologic events causing the fall).
The Joint Commission’s Office of Quality and Patient Safety has reviewed more than 350 patient falls during the last three years. While reporting a sentinel event to The Joint Commission is voluntary, health care organizations are still expected to conduct an internal comprehensive systematic analysis, regardless of if the event is reported or not.
The Joint Commission believes that more closely aligning its Sentinel Event Policy with established guidelines – such as the National Database of Nursing Quality Indicators™ and the National Quality Forum – will help expand knowledge around falls and implement more effective preventive measures. Also, The Joint Commission’s Center for Transforming Healthcare has a Targeted Solutions Tool® (TST®) for Preventing Falls that is available for free to all Joint Commission-accredited organizations.