The hospital staff is 100% responsible for preventing falls. This is one of a nurse’s and CNA’s (Certified Nursing Assistant) primary functions. This is because patient falls resulting in serious injury (including “any fracture”) are “sentinel events.” These sentinel events are events that should not happen because they are entirely preventable in a hospital setting.
The Joint Commission noted that sentinel events are usually caused by various factors including, but not limited to, “communication failures, lack of adherence to protocols or safety practices, inadequate staff orientation, supervision, staffing levels, and a lack of leadership.”
Sentinel events are also called “never events” by the National Quality Forum. The National Quality Forum notes that “patient death or serious injury associated with a fall while being cared for in a healthcare setting” should “never” happen. This is because hospital falls are entirely preventable.
The Leapfrog Group is an organization that maintains data regarding patient safety in a particular hospital and also provides resources and tools. Numerous Hostpitals are members of The Leapfrog Group. The Leapfrog Group affirms, “Some mistakes in the hospital are so egregious that they are referred to as never events.” As a result of these events, Leapfrog requested hospitals to commit to nine actions if a “never event” occurred: 1) Apologize to the patient, 2) Report the event, 3) Perform a root cause analysis, 4) Waive Costs directly related to the event, 5) Provide a copy of the hospital’s policy on never events upon request, 6) Involve patients in the root cause analysis when willing to participate, and three additional actions.
