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 partners with patients 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 also uses standardized ways of collecting and reviewing information about falls to facilitate improvement efforts. One way information is monitored is by using the National Quality Forum (NQF) “Serious Reportable Events” which are also called Leapfrog Never Events. Mayo Clinic continues to work on preventing falls, so they do not happen to other patients.

Mayo Clinic NQF reportable adverse health care events for falls from 2020-2023 are outlined in the graph below.

National Quality Forum (NQF) Fall Serious Reportable Event 2020 - 2023

What is Mayo Clinic doing to improve?

Specific Mayo Clinic initiatives have been implemented to decrease falls, including:

Mayo has launched an enterprise project to optimize the workflow in the electronic health record (EHR) for consistent documentation to enhance patient care providers' knowledge of patient fall history, fall risk and prevention measures in all inpatient and emergency department care areas.
Staff leverage technology such as video monitoring to identify patients at risk of falls.
Fall Champions/Safe Mobility Champions, local area experts and peer-to-peer leaders in fall prevention attend forums with physician fall leaders to promote best practices.
Staff identify patients with a fall risk using a flag in the EHR.
To help with safety of patients with transfers and walking, staff use equipment such as gait belts, walkers, and ceiling lifts.
Rochester is establishing, monitoring, and recommending appropriate institutional policies and practices for safe patient handling, culture of mobility, and fall prevention, including space planning, patient refusal to use safe patient handling equipment, and patient and staff education materials.
Arizona implemented an Ambulatory Fall Prevention Workgroup and will begin standardizing fall prevention across the ambulatory setting.
Florida is engaging multidisciplinary teams with safe patient handling rounding and incorporating discussion of fall prevention with patient safety rounds.
Eau Claire inpatient departments are creating individualized action plans to prevent falls.
La Crosse has implemented Safe Mobility Champions, combining expertise from safely handling patients and fall prevention.
Albert Lea/Austin is engaging multidisciplinary teams with safe patient handling rounding and incorporating discussion of fall prevention with patient safety rounds.
Mankato and Fairmont ambulatory and inpatient fall prevention committees have joined forces with safe patient handling to become the "Safe Mobility Committee." They will host a Safe Mobility Retreat in 2024. A multidisciplinary effort includes a "Within Arms Reach" and "Walk with Me" focus as well as patient education and audits for every unit.