![]() ![]() If so, you must conduct a root cause analysis (RCA.)īe aware that reporting sentinel events to TJC is voluntary. Then, when a fall occurs, you’ll need to review it against this new definition to determine if it qualifies as a sentinel event. Share the revised definition with your leaders and managers so they’re aware of the change. If you haven’t updated your Sentinel Event policy, now is the time to do so. Falls include any fall whether it occurred at home, out in the community, in an acute hospital, or ambulatory setting.” What to Do Now The fall may be witnessed, reported by a patient, an observer, or identified when the patient is found on the floor or ground. For consideration, a fall may be described as an unintentional change in position coming to rest on the ground, floor, or onto the next lower surface (e.g. The organization should choose a definition appropriate for the patient/client population served. Organizations are encouraged to check national guidelines and to check with their state to determine if any law/regulation exists defining a fall within the individual state. However, a uniform definition is needed throughout the organization. TJC Response: “No, The Joint Commission does not have an official definition of a ‘fall”. Question: Does The Joint Commission provide an official definition of a patient “fall” or does each organization need to define it? The World Health Organization defines a fall as “an event which results in a person coming to rest inadvertently on the ground or floor or other lower level.” Definition of a FallĪside from determining if a fall qualifies as a sentinel event, there is the basic question of: What is the definition of a fall? At the same time, there could also be falls that do indeed meet the definition for a sentinel event. ![]() ![]() “A 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).”Ĭlearly, with this definition of a “sentinel event fall,” there could be many falls in a behavioral health setting that would qualify as “incidents” but not sentinel events. The Joint Commission definition of a fall as a sentinel event is as follows: TJC Definition of Fall as a Sentinel Event Falls with serious injury are consistently among the top ten sentinel event reports to TJC. Most importantly, falls with injury are a significant patient safety problem. Specifically, only those falls that meet the Joint Commission definition would qualify as sentinel events. Thus, it doesn’t mean that every fall is automatically a sentinel event. ![]() The purpose for TJC including a definition of a fall as a sentinel event is to help organizations understand whether a fall qualifies for review as a sentinel event. The new definition went into effect January 1, 2021. As we work with clients on survey readiness, we’re noticing some organizations haven’t updated their Sentinel Event policy to include the Joint Commission definition of falls as sentinel events. ![]()
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