When a patient falls, your post-fall management should include a post-fall huddle and reassessment of the patient, according to a Sentinel Event Alert just released by The Joint Commission (TJC).1
Hold the huddle as soon after the fall as possible, TJC suggests, and involve staff at all levels. Also, if possible, discuss the fall with the patient, including what happened, how it happened, and why. For example, were there factors such as medication or a medical condition?
Also, TJC says the huddle should include the following: whether you had appropriate interventions in place, specific reasons why the fall might have happened, how you can avoid such falls, and how you will change the care plan. The huddle also should incorporate a standard post-fall huddle tool, the TJC says.
Ensure you have trending and analysis of falls for your QI efforts, the TJC says.
1. The Joint Commission. Preventing falls and fall-related injuries in health care facilities. Sentinel Event Alert 2015; 55. Accessed at http://www.jointcommission.org/assets/1/18/SEA_55.pdf.
