A System-Wide Approach to Prevention of In-Hospital Newborn Falls.

Area of Science:

• Healthcare Quality Improvement
• Patient Safety Research
• Infant Health

Background:

• Accidents, or unintentional injuries, are a leading cause of infant mortality.
• Analysis revealed newborn falls rates in family birth centers sometimes exceeded literature benchmarks.
• Infant falls represent a significant safety concern within birth hospitalization settings.

Purpose of the Study:

• To decrease the incidence of newborn falls during birth hospitalization.
• To address identified safety concerns through a multipronged approach.
• To evaluate the effectiveness of interventions in preventing newborn falls.

Main Methods:

• A quality improvement project was initiated by a nursing leadership team.
• Literature review, stakeholder input, and contributing factor analysis informed intervention development.
• Standardized interventions were implemented to prevent newborn falls.

Main Results:

• A downward trend in newborn falls was observed in 2017, but overall success is difficult to ascertain due to variable data and small numbers.
• Interventions focused on bed falls with mothers, the most common type of incident.
• The falls rate for newborns did not fall below comparable rates reported in existing literature.

Conclusions:

• More research is required to identify effective interventions for reducing newborn falls, especially from bed.
• A comprehensive strategy, informed by event analysis and evidence review, is essential for addressing this safety issue.
• Current interventions have not fully eliminated newborn falls during birth hospitalization.