An integrated regional healthcare system initiated a new program to reduce both the incidence of patient falls and fall-related injuries in acute care facilities. As part of this program, fall mats were deployed in inpatient areas as an injury prevention tactic. In January 2023, bedside staff at one facility noted several occurrences of liquid spilling onto and absorbing into the fall mats, causing them to become extremely slippery. This posed a serious safety risk to patients and staff as well as presenting an infection control concern.
These concerns were escalated through the health system’s tiered huddle process, triggering an initial review by the fall prevention committee, then a “device swarm,” a process the health system had developed to respond to complex device safety events or concerns. A multidisciplinary team that included nursing, employee health and safety, patient safety, and the vendor was convened to assess the concerns and discuss mitigation strategies. When it became apparent that the concerns could not be sufficiently resolved to ensure staff and patient safety, the health system issued an internal recall to remove the fall mats from use. With the immediate risk contained, attention then turned to identifying an alternative fall mat product, given that they are an evidence-based tool for fall injury prevention.
The system’s Clinical Equipment Review Team (CERT) coordinated a comprehensive evaluation of fall mats to find the safest product and engaged an external vendor to evaluate fall mats from different manufacturers to assess their coefficient of friction (i.e., how slippery they are) when dry and wet. These efforts helped identify a clinically acceptable, low-profile fall mat product.
The multidisciplinary team performed a failure modes and effects analysis (FMEA) on fall mat deployment, identified high-risk components of the process, and recommended mitigation measures. Before their deployment, systemwide communication went out to alert all staff to the presence of mats in inpatient clinical areas, encouraging them to be aware of their surroundings and instructing them how to report concerns with the mats. Robust training was provided for nursing and rehabilitation medicine staff on how to safely work with the fall mats and configure patient rooms to optimize safety. Environmental services staff were trained in proper cleaning techniques.
Since the mats were deployed in November 2023, 11 patients have fallen on them without being injured. The multidisciplinary team continues to track and trend any fall mat–related concerns and works collaboratively to resolve any newly identified issues. This exemplar shows the power of transparently sharing a safety concern to prevent patient and staff harm. Bedside staff were empowered to speak up about a safety hazard, which was promptly escalated through a hardwired, tiered huddle process. From there, leader engagement and safety science methodologies came together to minimize risk.
