TJC: Time to curb patient falls in healthcare settings.

Noting that there are far too many falls in healthcare settings, The Joint Commission (TJC) has issued a Sentinel Event Alert, telling hospitals and other providers to take steps to identify patients at risk for a fall, and implement preventive interventions. However, while most falls occur in hospitals, preventing falls in the emergency setting presents some unique challenges. Since 2009, TJC says it has received 465 reports of patient falls with serious injury, and more than half of these have resulted in death. Most fall risk assessment tools are too cumbersome and take too long to complete at triage in the ED. The ED at Hartford Hospital in Hartford, CT, has implemented a streamlined risk assessment tool with just five "yes or no" factors for the triage nurse to consider. In concert with the risk assessment tool, the hospital has implemented a series of prevention interventions, including hourly rounding, bed alarms, post-fall huddles, and a non-punitive culture for reporting falls.