Proposed change:

Implementation, outcomes and evaluation:

Implications for nursing practice:

Keywords:    Proposed change:  At Andrews Women's Hospital, we had experienced 8 infant falls in the first two years that our doors had been open. The proposed changes were to hardwire hourly rounding on all shifts, to educate the families on safe sleeping arrangement and to promote maternal rest.  Our goal was to eliminate infant falls at Andrews Women's Hospital

Implementation, outcomes and evaluation: We implemented the project by, first, using a tally sheet to identify common trends in the newborn falls that had occurred.  Then, we educated both the Newborn Nursery and the Postpartum staff on the need to hardwire the hourly rounding on all shifts.  Next, we developed a Newborn Safety Sheet that described the elements of safe sleeping, and required that both mom and Significant other sign it (since three of our babies had been dropped by Dads).  In addition, we emphasized with the Newborn Nursery staff and Postpartum staff how important it was that we make sure that mom has the call bell within reach even when we get her up to a chair, in case she needs something.  Next, we began an extensive campaign to make sure that mom understood the side effects of her pain medication.  In addition, the Postpartum RN would alert the Nursery RN when mom had taken pain medication.  Finally, we initiated "Snuggle Time" everyday from 2:00-4:00 to promote maternal rest without interruptions.  The outcome has been very positive.  We have just hit the one-year mark since our last fall.    Implications for nursing practice: Education of the families and hourly rounding are a dynamite duo and absolutely necessary in keeping our infants safe.