• PR: New Alert Discusses Prevention of Patient Falls (PDF/QV) [REF: PI, RN] Perspectives November 2015, Vol 35, #11, Pg 4 JCp1511_B2

Sentinel Event Alert #55 is most likely based in part on the fact that falls with injuries has consistently been among the top 10 Sentinel Events reported to TJC for a number of years. The article lists some of the most common factors contributing to falls with injury and inadequate assessment and communication failures head the list.  It also contains the full alert text along with a series of 6 suggested actions for reducing this risk.  Among these are the use of a standardized, validated tool for the identification of fall risk factors. The Morse and Hendrick tools are listed, but the Edmonson Psychiatric Fall Risk Assessment Tool (EPFRAT) was not.  This raises a question about the potential relevance of the alert to our specialty hospitals.  Still, fundamental principles (e.g., hand-off communication, patient education) are certainly applicable to all hospitals as are the 7 hospital-related requirements/standards listed in a chart on page 7.
Tip1: Clinical leadership should review the alert and look for opportunities within its suggestions to strengthen your facility’s fall reduction efforts.
Tip2: After 3 years of development, the Illinois Department of Mental Health is about to launch the statewide implementation of a standardized fall risk assessment process using a refined version of the Edmonson tool that may well be worth watching. For more information on the initiative see the comments section of this article for an Illinois contact person.
See also: New Sentinel Event Alert on Patient Falls below. Source, Nov 2015, vol 13 #11