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A Comprehensive Newborn Falls Prevention Strategy: The First Two Years Rose Mary Ainsworth, RN, MSN, Jeanette Atkinson, RN, Cathy Mog, RN, Shelley Summerlin-Long, RN, MPH, MSW Huntsville Hospital for Women & Children, Mother/Baby Unit, Huntsville, Alabama
Background and Project Objective
Staff Education and Tools
Results and Conclusions
Common factors in falls events: Cesarean delivery, narcotics use, feeding times, early morning hours
Anonymous survey administered to staff to assess usage of individual components of newborn falls protocol - at 6 months and 1 year
100% of staff attended Newborn Falls class
99% reported having read new Newborn Falls policy
Round 1: 89% of nurses report using the Newborn Falls Assessment at least once each shift; 95% in Round 2
Staff Survey on Implementation of Newborn Falls Protocol
Scale:
1 = Never
7 = Always
Huntsville Hospital has had three fall incidents in past two years since falls protocol implemented, but they do not fit previous pattern. In one case, infant fell from mother’s arms but not from bed as mother’s siderails were up.
Mother/Baby administrators and staff plan to continue use of staff and family educational tools and the Newborn Post-Fall Debriefing Form to evaluate all future infant falls and to develop additional tools and strategies as indicated by future data collection. Other hospitals seeking to reduce and prevent newborn falls may learn from Huntsville Hospital’s experience in its newborn falls initiative.
Baby drop definition – “A fall in which a newborn, infant, or child being held or carried by a health care professional, patient, family member, or visitor falls or slips from that person’s hands, arms, lap, etc. when a child is being transferred from one person to another. The fall is counted regardless of the surface on which the child lands (e.g. bed, chair, or floor) and regardless of whether or not the fall results in an injury.” (National Database of Nursing Quality Indicators [NDNQI], fall indicator established for 2nd quarter, 2013)
Issue of newborn falls (drops) in the hospital only recognized as a problem in recent years
Little in literature to provide evidence-based guidelines for uniform health care policy response
Hospitals developing own strategies for reduction/prevention of newborn falls
Huntsville Hospital had 7 newborn falls in 7 month period (Dec July 2012), and the issue of Newborn Falls was designated a Quality Initiative
Objective: To reduce and prevent newborn falls at Huntsville Hospital for Women & Children
Staff educated on falls through required class, staff meetings, s and flyers
Newborn Fall Risk Assessment Tool created
and implemented in September Nurses
assess patients at least once a shift and as needed
when variables change during shift.
Newborn Post-Fall Debriefing Form created for use by health care team after fall events
Family Education
Large focus on educating families about newborn fall prevention
Nurses educate family members on falls at beginning of each shift, when giving pain medication and as needed
Patients instructed to call nurse before and after infant feedings so that four siderails can be raised/lowered as falls prevention method. Reminder posters in patient rooms (siderails policy approved by hospital administration)
Falls information added to Infant First
Instruction and Safety Sheet read
and signed by patients at admission
(in English and Spanish)
Information on newborn falls posted
on mirrors in patient bathrooms
Postpartum booklets and crib cards
updated to include information on
newborn falls
Methods
Mother/Baby unit staff formed a committee to:
Review information from the 7 fall events, other hospitals’ experiences and the literature
Review of 7 fall events included variables such as type of delivery, maternal pain medication/PCA use, time of day fall occurred, where baby was, whether baby feeding, and other circumstances at time of fall.
Create a policy on newborn fall prevention
Develop education and tools for family members and staff
References
Newborn Falls Policy
Abike F, Tiras S, Dunder I, Bahtiyar A, Uzun OA, Demircan O. (2010). A new scale for evaluating the risks for in-hospital falls of newborn infants: a failure modes and effects analysis study. International Journal of Pediatrics, 2010, 9 p.
Helsley L. (2011). Newborn falls/drops in the hospital setting.  [PowerPoint slides].Retrieved from
Helsley L, McDonald JV, Stewart VT. (2010). Addressing in-hospital “falls” of newborn infants. Joint Commission Journal on Quality and Patient Safety,36(7),   
Monson SA, Henry E, Lambert DK, Schmutz N, Christensen RD. (2008). In-hospital falls of newborn infants: data from a multihospital health care system. Pediatrics, 122(2), e277-e280. National Database of Nursing Quality Indicators (NDNQI). (2013). Nursing Quality News, 14(1), p. 3.
Paul SP, Goodman A, Remorino R, Bolger S. (2011). Newborn falls in-hospital: time to address the issue. Pract Midwife, 14(4),
Phalen AG, Smolenski J. (2010). Newborn falls: seeking solutions for a never event. Journal of Obstetric, Gynecologic, & Neonatal Nursing (Special Issue: Proceedings of the 2010 AWHONN Convention), 39(1), S46.
Ruddick C, Ward Platt M, Lazaro C. (2010). Head trauma outcomes of verifiable falls in newborn babies. Arch Dis Child Fetal Neonatal Ed, 95, F144-F145.
Schwartz DL, Hitchcock SC. (2012, June). Help! Our babies are falling!: A maternal-newborn case study. Poster session presented at the national conference of the Association of Women’s Health, Obstetric, and Neonatal Nurses, Washington, D.C.
Policy and Procedure on Newborn Falls Prevention created and implemented in July 2012
Addresses parental education, infant transport, placement of infant for sleeping, review of maternal medications, assessment of environment and mother’s level of consciousness, and required actions in the event of maternal seizure precautions