Mayo Clinic Fall Prevention

Falls are one of the most common adverse events among hospitalized patients. Falls that result in an injury can increase a patient's length of stay and increase the risk of complications and mortality, particularly among older adults.

Mayo Clinic is committed to partnering with patient and families to decrease fall injuries.

What does Mayo Clinic measure?

Mayo Clinic uses falls data to identify opportunities to reduce patient falls. Mayo Clinic benchmarks the data by using mandated reportable adverse health care events, National Quality Forum ''Serious Reportable Events'' and Leapfrog "Never Events":

  • The Minnesota Hospital Association and the Minnesota Department of Health created a list of mandated reportable Adverse Health Care Events. The mandated reportable adverse health care events were built on the National Quality Forum's "Serious Reportable Events," including a patient death or serious injury associated with a fall while being care for in a facility.
  • The Leapfrog "Never Event" aligns with as the National Quality Forum Never Events and the mandated reportable Minnesota Adverse Health Care Events. Leapfrog Group is an independent nonprofit group that provides a Leapfrog Hospital Safety Grade.
  • The "Adverse Health Care Events," National Quality Forum's Serious Reportable Events and Leapfrog "Never Event" are extremely rare events that should not happen to a patient in the hospital. Mayo Clinic works to prevent these rare events from happening to other patients.

How is Mayo Clinic performing?

Mayo Clinic Leapfrog reportable adverse health care events in terms of falls for 2018-2021 are outlined in graph below. This graph highlights the progress that Mayo Clinic has made in decreasing patient falls with injury from 2018-2021.

National Quality Forum (NQF) Fall Serious Reportable Event

Chart.

Data source: Mayo Clinic incident reporting 2018-2021.

What is Mayo Clinic doing to improve?

Specific Mayo Clinic Leapfrog Hospital initiatives have been implemented, including:

  • Piloting an electronic board for communication to all multidisciplinary staff about the patient fall risk in Mayo Clinic in Arizona.
  • Developing site-specific multidisciplinary falls executive team at Mayo Clinic in Florida to ensure that staff can execute various interventions without a barrier. Mayo Clinic in Florida is also testing a product that alerts the nurse before the patient falls out of the bed. The alarms are based on certain movements that indicate the patient is about to try to get out of the bed.
  • Working on unit-specific fall prevention action plans such as My Plan for Safe Activity poster, Bedside Mobility Assessment Tool (BMAT), and "Rule-out" criteria for Within Arm's Reach at Mayo Clinic in Rochester, Minnesota.
  • Using A3, a quality improvement tool, problem-solving approach in Austin, Minnesota, to help create fall action plans.
  • Increasing awareness using visual management boards in Red Wing, Minnesota, that informs patients and visitors about quality improvement work.
  • Engaging patients and families in fall prevention with the use of a "My Plan for Safe Activity" visual at Mayo Clinic Health System in Fairmont, Minnesota.
  • Piloting an electronic health record to identify patients who are at a high risk for falling as well as using fall risk door magnets as a visual for anyone entering a room who may not be directly involved in the patient care at Mayo Clinic Health System in Mankato, Minnesota.
  • Piloting a tool for patients sitting in a chair that would notify staff when the patient tries to get up from the chair at Mayo Clinic Health System in Eau Claire, Wisconsin.
  • Increasing awareness with audits and education at Mayo Clinic Health System in La Crosse, Wisconsin.

Other activities include:

  • Focusing work on fall prevention for patients with cognitive impairment, delirium, and dementia
  • Using technology such as video monitoring to assist in identifying patients at risk of falling
  • Sharing best fall prevention practices across sites and efforts shown to be effective in creating a safe environment and reducing patient falls through an institution-wide falls networking group
  • Knowledge sharing by Fall Champions, who are local area experts and peer-to-peer leaders in fall prevention efforts, at forums with physician fall leaders
  • Applying an inpatient risk assessment tool that helps develop an individualized care plan based on identified fall and injury risks and implement patient-specific interventions
  • Identifying patients with a fall risk using a flag in the electronic health record
  • Using equipment such as gait belts, walkers and ceiling lifts during transfers and walking to improve safety for patients
  • Developing a Fall Prevention Playbook as a guide for the multidisciplinary team in fall prevention
  • Developing a staff video for empathetic communication with patients who refuse fall prevention interventions

Mayo Clinic also uses its data and network across all locations to explore other opportunities to prevent injuries associated with falls.

Current Initiatives:

  • Lap Belt pilot
  • Bed Sensors pilot
  • Chair alarms with flag outside of room

Resources

Mayo Clinic Healthy Aging Falls Prevention: Simple tips to prevent falls