Protecting Our Littlest Patients: A Newborn Falls Prevention Strategy

Background: The issue of newborn falls (drops) in the hospital is one that has only been recognized as a problem in recent years.  With little in the literature to provide evidence-based guidelines for a uniform health care policy response, hospitals are developing their own strategies to reduce and prevent newborn falls. 

Objective:

To reduce and prevent newborn falls at Huntsville Hospital for Women and Children

Design: Evidence-based quality improvement project

Sample: Mother/Baby Patients and Staff at Huntsville Hospital for Women and Children

Methods:

There were seven newborn falls during a seven-month time period on the hospital’s postpartum unit. After the first falls, the unit formed a committee to create a policy on newborn fall prevention and to develop education and tools for family members and staff to decrease the incidence of infant falls/drops. Committee members used information from review of the seven falls events, from a comprehensive literature review on newborn falls, and from information collected by the unit’s Nurse Manager from other hospitals with similar numbers of deliveries.

Implementation Strategies:

As a result of the committee’s work, the following interventions targeting family members have currently been implemented: information on newborn falls added to safety instruction sheet read to, given to, and signed by parents at admission; new crib cards with information on falls prevention; room posters and mirror clings with falls information created; and falls information to be added as a crawl on unit’s Newborn Channel.  Parents are also educated on newborn falls during childbirth classes. Strategies targeting staff members include staff education on falls through a mandatory class, emails, staff meetings, and unit flyers; a new Fall Risk Assessment Tool added to charting system; and a Newborn Post-Fall Debriefing Form created for use after fall events.  The Newborn Falls Policy is now in use and includes protocol for parental education, infant transport, placement of infant for sleeping, review of maternal medications, assessment of environment and mother’s level of consciousness, and actions for preventing falls during infant feedings. In addition, Falls Committee staff members are meeting with pediatricians who see patients at Huntsville Hospital in order to plan a unified protocol for physician response to newborn falls.

Results:

No newborn falls have occurred in the time period since the implementation of this comprehensive falls prevention strategy.

Conclusion/Implications for nursing practice:

Other hospitals seeking to reduce and prevent newborn falls may learn from the experience of Huntsville Hospital in its newborn falls initiative.

Keywords: Newborn falls, patient safety, staff and patient education