Patient Falls Rose At Hospitals As ‘Sentinel Events’ Increased In Pandemic

Patient falls at U.S. hospitals rose significantly last year as potentially deadly “sentinel events” increased during the Covid-19 pandemic, according to a new report from The Joint Commission, accreditor of thousands of U.S. healthcare facilities.

The report, which is based on voluntary reports to The Joint Commission, is a snapshot into patient safety at hospitals and other healthcare facilities and comes at a time healthcare providers are increasingly measured on their performance. Healthcare facilities with higher error rates or poor health outcomes can face penalties and lower reimbursement rates from both government and private health insurance companies.

The Joint Commission classifies a sentinel events as “a patient safety event that results in death, permanent harm or severe temporary harm.” Patient falls are the most commonly reported sentinel event and remained so in 2022 at 42% or those reported. “The remaining leading categories were delay in treatment (6%), unintended retention of foreign object (6%), wrong surgery (6%) and suicide (5%),” the Joint Commission said.

“Falls have been the leading sentinel event type reviewed since 2019,” the Joint Commission’s 2022 sentinel event data review shows.

“There were 611 sentinel events classified as patient falls in 2022 – a 27% increase from 2021,” the report continued. “Of these patient falls, 5% resulted in death and 70% in severe harm to the patient. Leading injuries included head injury/bleed and hip/leg fracture.”

The Joint Commission, which reviewed more than 1,400 sentinel events last year, blamed “failures in communication” and healthcare providers not “consistently following policies” as the leading causes of sentinel events. Nearly 90% of sentinel events occurred in a hospital, the Joint Commission said.

“COVID-19 continued to present challenges to healthcare organizations throughout 2022, and we saw the number of sentinel events increase above pre-pandemic levels,” The Joint Commissions chief patient safety officer and medical director, Dr Haytham Kaafarani said in a statement accompanying the report. “For each sentinel event, a Joint Commission patient safety specialist worked with the impacted healthcare organization to identify underlying causes and improvement strategies. Our goal is to help prevent these types of adverse events from occurring again.”