Mayo Clinic Falls 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 formed the Reducing Falls with Injury Quality Improvement team to reduce falls with injury. The four focus areas are:

  • Risk assessment for inpatient and ambulatory practice
  • Education
  • Multidisciplinary collaboration
  • Data and reporting

Falls are also a Mayo Clinic top safety issue for 2021.

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 cared 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 2018-2020 are outlined in the graph below. The data demonstrates Mayo Clinic's progress in decreasing falls with injury throughout the years.

National Quality Forum Fall Serious Reportable Event

Chart.

Data source: Mayo Clinic incident reporting, 2018-2020.

What is Mayo Clinic doing to improve?

Mayo Clinic formed a work group to reduce falls with injury.

Specific Mayo Clinic initiatives have been implemented, including:

  • Completing a prevalence study at Mayo Clinic in Arizona to identify practice gaps and education needs to strengthen the culture of safety regarding harm caused by inpatient falls.
  • Developing site-specific videos at Mayo Clinic in Florida on the importance of staff involvement for patients going to the bathroom (part of the Within Arm's Reach program).
  • Working with units on plans for safe activity at Mayo Clinic in Rochester, Minnesota.
  • Conducting audits at Mayo Clinic Health System in Austin, Minnesota, to ensure completion of fall best practices.
  • Reviewing all falls at Mayo Clinic Health System in Red Wing, Minnesota, to see trends and identify gaps and opportunities for improvement.
  • Piloting "patient contracts" at Mayo Clinic Health System in Fairmont, Minnesota. A patient contract is a document that the patient and nurse review together and sign outlining responsibilities of the patient and nurse.
  • Increasing the inventory of chair and bed alarms so that the two alarm types are paired in all patient rooms at Mayo Clinic Health System in Mankato, Minnesota.
  • Implementing the Walk with Me and Within Arm's Reach programs in surgical and procedural areas at Mayo Clinic Health System in La Crosse, Wisconsin.
  • Increasing awareness with audits and education at Mayo Clinic Health System in Eau Claire, Wisconsin.

Other activities include:

  • Standardizing and applying best practices and interventions demonstrated to be effective in creating a safe environment and reducing patient falls.
  • Implementing Nursing Fall Champions, who are local area experts and peer-to-peer leaders in fall prevention efforts.
  • 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.
  • Screening ambulatory patients to identify those who may be at risk of falling.
  • 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.
  • Developing the Within Arm's Reach and Walk with Me programs to assist patients in the bathroom and when walking to appointments.

Mayo Clinic also continues to use its data and network across all locations to explore additional opportunities to prevent injuries associated with falls.