The Joint Commission issued a Sentinel Event Alert focused on preventing patient falls, identifying a number of factors that contribute to the problem, including a lack of hospital leadership.

"Fall prevention is the responsibility of everyone in the organization and success is highly dependent on leadership playing a primary role," said Ana Pujols McKee, M.D., executive vice president and chief medical officer, in a Joint Commission news release. "It is their commitment and approach that determines an organization’s ability to significantly reduce and sustain the reduction in falls,” McKee said.

Among the other conditions that lead to unnecessary falls are inadequate assessment, communication failures and lack of adherence to protocols and safety practices, according to the release.

The issue of addressing patient falls has been a vexing one, with providers adopting a number of strategies to reduce them. In Nebraska, 19 hospitals are working together within an Agency for Healthcare Research and Quality initiative to reduce falls, while a clinic at Wexner Medical Center at The Ohio State University puts a heavy emphasis on preventing falls in the home.

The Joint Commission move follows the unveiling last month of the Preventing Falls Targeted Solutions Tool by the Joint Commission Center for Transforming Healthcare.

In July, HHS launched an online course to help clinicians prevent falls in older patients.

The Health Research & Educational Trust, part of the American Hospital Association, also offers tools targeting a reduction in patient falls through its Hospital Engagement Network. The AHA's HEN recently received additional grant funding from Centers for Medicare & Medicaid Services as part of a larger HEN allocation.

Sentinel event alerts are designed to highlight the underlying causes of sentinel events and adverse events, and suggest ways to reduce the problem.