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 patients and families to decrease fall injuries.

What does Mayo Clinic measure?

Mayo Clinic uses falls data to identify opportunities to reduce patients 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 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 continues to work on these rare events so they do not happen to other patients.

How is Mayo Clinic performing?

Mayo Clinic Leapfrog reportable adverse health care events in terms of falls for 2019-2022 are outlined in a graph below. This graph highlights the progress that Mayo Clinic has made in decreasing patient falls with injury from 2019-2022.

National Quality Forum (NQF) Fall Serious Reportable Event 2019-2022

Data source: Mayo Clinic incident reporting 2019-2022.

What is Mayo Clinic doing to improve?

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

• Developing an enterprise workgroup to focus on the fall workflow process as well as optimize the electronic health record for consistent documentation in all patient care areas and enhance a "flag" to show patient fall risk and history.
• Future enterprise projects include ensuring that correct individualized interventions/actions are taken from fall risk assessment tools, medications, diagnosis and fall history documentation when fall risk assessment is positive.
• Rochester is exploring work on cognitive impairment, fall risk assessment and generation of an individualized care plan. Rochester developed a patient education and engagement in safe mobility algorithm.
• Arizona is piloting an ambulatory fall risk question validation tool in partnership with the Kern Center for the Science of Health Care Delivery.
• Florida developed a "fall playbook" and completed a quality improvement project that developed a new fall risk category and decreased falls for a specific patient population.
• Eau Claire has increased visibility of falls work by having a fall prevention month, recognition program and "know your numbers" program.
• LaCrosse is exploring a research project to determine if the type of scale and the clinical processes used to obtain a patient's weight contributes to falls.
• Albert Lea/Austin developed a video on preventing falls by communicating with empathy for staff.
• Mankato worked with an electronic health record vendor to develop a fall prediction model.
• Fairmont developed "fall champions" to help increase awareness and resources at the unit level for fall prevention.

Other activities include:

• Focused work on fall prevention for patients with cognitive impairment, delirium, and dementia.
• Leveraging technology such as video monitoring to assist in identifying patients at risk of falls.
• Enterprise falls networking group will share best fall prevention practices across sites. Interventions were demonstrated to be effective in creating a safe environment and reducing patient falls.
• Fall Champions, who are local area experts and peer-to-peer leaders in fall prevention efforts, attend forums with physician fall leaders to discuss best practices.
• Applying an inpatient risk assessment tool that helps develop an individualized care plan based on identified fall and injury risks and implementing patient-specific interventions.
• Identifying patients with a fall risk using a flag in the electronic health record.
• To help with safety of patients with transfers and walking, staff use equipment such as gait belts, walkers and ceiling lifts.
• Fall Prevention Playbook developed 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 continues to use its data and network across all locations to explore additional opportunities to prevent injuries associated with falls.

Resources

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

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