Patient falls associated with healthcare delivery are frequent, undesirable, and largely preventable events. Patients who receive conscious sedation for endoscopic procedures are especially vulnerable to falls because of the cognitive effects of the sedation, relative hypotension that may be induced by the most common sedatives used (fentanyl and midazolam), the prolonged fasting state, and the frequent practice of withholding regular daily medications prior to procedures. There is a need to evaluate patient falls after sedated endoscopic procedures.
The objective of this study was to create a quality improvement project to first analyze the root cause in the patients who fell and then to create a low-cost intervention that could be rapidly and effectively implemented.
The study took place in the Division of Gastroenterology and Hepatology at Mayo Clinic Rochester and encompassed two hospital and one outpatient endoscopy suites that collectively perform approximately 40,000 sedated endoscopic procedures per year. During the study period, there were 64 board-certified gastroenterologists who were responsible for performing endoscopy and approximately 85 nurses.
The introduction of the patient fall-risk screening process significantly reduced patient falls following sedated endoscopic procedures.
It is possible that the occurrence of patient falls may have been missed in the period of study. Further, most patients who come for endoscopic procedures are without significant comorbidities, including orthopaedic and neurological disease which may contribute to self-selection bias and unintentionally amplify the success intervention.