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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