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HQS 509- Unit 5 Discussion: Sentinel Events

Aug 18, 2023

    Unit 5 Discussion: Sentinel Events

    The text references a specific type of error called a Sentinel Event.  Visit The Joint Commission Sentinel Event Alert Newsletter site. (Links to an external site.)

    • Select one of the numbered alerts that are of particular interest to you. 
    • Describe the content of the alert – what it means, and what recommendations are offered to prevent this type of serious error from happening. 
    • Include any data that is provided in the alert you choose.

    Unit 5 Discussion: Sentinel Events

    The topic which I want to highlight for this week’s discussion from the list of sentinel events is the number 55, which mainly highlighted the cases of preventing falls and fall-related injuries in health care facilities. Studies have shown that in the hospital environment fall-related injury cases are very vulnerable and always have to take proper care to improve the quality of care and the safety guidelines for the patients (Peng et al. 2019, p.11).  Falls and injuries in the hospital are the most prevalent patient problems. It also needs to be highlighted that, not only elderly patients face this kind of problem but also children and young adults may undergo these adverse consequences. The possible causative factors responsible for the occurrence of these negative circumstance which has been highlighted by the Joint Commission includes inadequate assessments, lack of communication among the medical professions, lack of adherence to the hospital protocols, lack of control by the leaders, and the higher authorities in providing the appropriate tools and infrastructure, inadequate staff coordination’s, supervision and many more. Studies have reported that the data describing the adverse cases of these incidences are quite surprising. The joint commission has reported that, in the United States, hundreds of thousands of patients reported cases of falls in hospitals, with 30-50% resulting in severe injuries. Not only these circumstances are harmful to the patients, but they also affect the hospital services to a greater extent. Injured patients have to stay long in the hospital for additional treatments which increases the costs for the cases of falls from injuries to near about $14.000 (Baris, Intepeler & Yeginboy, 2018, p.163).

    The suggestive measures, which can be recommended to prevent this kind of fatal case include increasing awareness by providing proper education and training among the clinical and non-clinical staff. Appropriate use of the infrastructure, tools, more staff empowerment, and safety alarms should be encouraged. The establishment of an interdisciplinary injury prevention team should be done to evaluate the loopholes and take proper actions in the management of these loopholes. Initiatives of introducing advanced, standardized, and validated tools to handle the immobile, elderly, and vulnerable patients to avoid any negative consequences should always be encouraged. A screening to identification of the risk of falling for each patient should be done because this will not only help the medical staff to be careful about that patient but will also help in the early identification of vulnerable patients. Patient and staff communication should be enhanced to prevent this scenario. A monthly or half-yearly report regarding the fall and the injuries in the hospital should be encouraged to track the record of these cases this does not only have documentation but will be helpful in the identification of the areas where special care should be taken.


    Baris, V. K., Intepeler, S. S., & Yeginboy, E. Y. (2018). The cost of serious patient fall-related injuries at hospitals in Turkey: A matched case-control study. Clinical nursing research27(2), 162-179.

    Peng, K., Tian, M., Andersen, M., Zhang, J., Liu, Y., Wang, Q., … & Ivers, R. (2019). Incidence, risk factors and economic burden of fall-related injuries in older Chinese people: a systematic review. Injury prevention25(1), 4-12.

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