Falls remain a serious threat to patients in the health system. In 2019-20, there were 25 sentinel events reported to Safer Care Victoria (SCV) that were directly attributed to falls. We’re committed to improving outcomes from falls adverse event reviews.
SCV partnered with health services to pilot the Falls Review Tool. Participating health services provided valuable feedback during the pilot to improve the tool and user guide. The Falls Review Tool is now available for health services to use, accompanied by a user guide, which also contains instructions on how to use the tool for a sentinel event.
The Falls Review Tool has been designed to assist health services to:
- understand their current state in relation to falls prevention
- streamline the review process
- use a human factors (systems thinking) approach to serious Falls Incident reviews
- strengthen recommendations resulting from falls reviews
For a trial period commencing 1 November 2022, falls directly causing serious harm or death do not require notification as a sentinel event. We recommend that falls resulting in serious harm or death are reviewed using the Falls Review Tool. This should be done in conjunction with robust internal health service monitoring and governance processes, in line with the National Safety and Quality Health Service Standard 5 Comprehensive Care.
Patient Safety Review Team
Sentinel Event notifications and falls