Partnering with Parents: Preventing Infant Falls

Purpose for the program:

In December 2011, a report generated from the on-line incident reporting system identified three (3) infant falls (6.6 falls per 10,000 births) had occurred  Previously, two (2) infants falls (4.4 falls per 10,000 births) in 2009, no infant falls in 2010 were reported. All were on the night shift with the mother reporting she fell asleep.  None of the newborns suffered serious injury.  The mother/baby unit had just completed a project to increase exclusive breastfeeding and more infants were rooming-in (>70%). There was concern on the part of the staff that the new mother/baby care delivery model would be blamed for the increase in falls. The hospital had also recently purchased new beds where the side rails were not as high when the head of the bed was elevated and may have been contributory.

Proposed change:

To fully evaluate contributory factors related to infant falls on the mother/baby unit and develop safety strategies to reduce/eliminate infant falls by instituting a Newborn Safety Partnering Agreement for Parents

Implementation, outcomes and evaluation:

An increase in infant falls on the mother/baby unit prompted review to identify potential contributory factors which included: exhaustion of mother after delivery, bed siderail position, too many pillows, timing/type of pain medication, cultural issues and unsafe parental behaviors.  A query was sent out to the NY Organization of Nurse Executives list serve requesting any infant fall prevention programs that were successful.  The query and literature review yielded minimal results. An infant safety checklist was developed to include awareness for potential falls.  Based on feedback, the checklist evolved into a Newborn Safety Partnering Agreement for Parents and fall debrief tool to be used after a fall to immediately identify contributing factors. The premise behind the partnering agreement was to raise parents’ awareness for the potential for an infant fall beyond traditional patient education.  The tool is used to educate and ask parents to partner with staff to keep their baby safe. A pilot to evaluate effectiveness was conducted.  Minor changes to the tool and implementation of the agreement in the Delivery Room prior to delivery proved successful. With implementation of the Newborn Safety Partnering Agreement for Parents, there have been no infant falls to date.

Implications for nursing practice:

Implementation of a Newborn Safety Partnering Agreement for Parents on the mother/baby unit raises awareness to prevent infant falls and injury.

Keywords: Infant Safety

Infant Fall Prevention

Parent partnering