![]() 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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