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Review patient falls, especially those involving infants, as surveys resume


April 1, 2021

by A.J. Plunkett (aplunkett@decisionhealth.com)

Review how your hospital did in reducing falls, unintentional retention of foreign objects, suicides, delays in treatment, and wrong surgery in the last year. Those five sentinel events  are once again in the top five of patient safety problems reviewed by The Joint Commission (TJC) in 2020, according to recently released statistics.

In highlighting the most commonly reviewed sentinel events, TJC officials brought special attention to falls involving infants as “an underrecognized issue” among other patient falls.

TJC reminded organizations that, according to its Quick Safety Report No. 40, issued in 2018, “Preventing newborn falls and drops,” that maternal risk factors for infant falls included problems related to Cesarean birth, use of pain medication within four hours, issues on the second or third postpartum night, specifically midnight to early morning hours, and drowsiness associated with breastfeeding.

The commission has been pushing hospitals to focus on maternal health and infant safety for years, and most recently implemented new maternal health standards.

Overall, patient falls held the top spot for 2020 sentinel events with 170 incidents reviewed by TJC, the highest since 2005.

Almost 90% of the 794 overall sentinel events reviewed by TJC were voluntarily self-reported, and officials reiterated that “it is estimated that less than 2% of all sentinel events that occur in health care are reported to The Joint Commission. Therefore, these data are not an epidemiologic data set, and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.”

TJC said it “works with organizations reporting sentinel events to identify contributing factors and actions the organization can take to reduce risk.”

For more on sentinel events, go to TJC’s patient safety page at https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/.


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