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October 2015

“To Err Is Human,”

In 1999, an Institute of Medicine report, “To Err Is Human,” documented serious patient safety problems in our health care system. In the intervening years, the Agency for Healthcare Research and Quality (AHRQ) has led the Nation in responding to those issues and improving the safety of health care.  AHRQ is the lead Federal agency charged with improving the safety and quality of America’s health care system.

Sentinel Event Alert Issue 55: Preventing Falls and Fall-Related Injuries in Health Care Facilities

On September 28, 2015, the Joint Commission published their Sentinel Event Alert Issue 55: Preventing falls and fall-related injuries in health care facilities.  This publication provided an  overview of the tools that have been developed through research and quality improvement initiatives, including the Center for Transforming Healthcare's Preventing Falls Targeted Solutions Tool® (TST®).   In the issue it states, “Falls with serious injury are consistently among the Top 10 sentinel events reported to The Joint Commission’s Sentinel Event datab

new Preventing Falls Targeted Solutions Tool®(TST®)

The Joint Commission Center for Transforming Healthcare is promoting their new Preventing Falls Targeted Solutions Tool®(TST®).  This tool can help organizations reach their goals in reducing falls.  The Joint Commission also has Targeted Solutions tools for Hand Hygiene, Safe Surgery and Hand-Off Communications.  The NEW Preventing Falls TST® is complimentary to Joint Commission accredited organizations and is separate from accreditation–surveyors do not have access to TST® data.