Implementation of a Comprehensive Safety Bundle to Support Newborn Fall/Drop Event Prevention and Response

Area of Science:

• Healthcare quality improvement
• Patient safety in obstetrics
• Pediatric fall prevention

Background:

• An eight-hospital system observed an increase in newborn fall/drop events, with one hospital doubling its reported incidents in FY2016.
• Injuries from these events included skull fractures and hematomas, necessitating NICU admission and extended hospital stays.

Purpose of the Study:

• To develop and implement a comprehensive Newborn Fall Safety Bundle for preventing and responding to newborn fall/drop events.
• To significantly reduce the incidence of newborn fall/drop events across the entire health system.

Main Methods:

• A performance improvement initiative utilized the Plan-Do-Study-Act model.
• A multidisciplinary task force comprising nurses, educators, and physicians identified contributing factors and developed evidence-based interventions.
• Root cause analysis and Pareto principles guided the problem evaluation and intervention prioritization.

Main Results:

• Sustained practice alignment with the Newborn Fall Safety Bundle exceeded 90%.
• The organization achieved a 36% reduction in newborn fall/drop events between FY2016 and FY2017 (from 6.66 to 4.06 per 10,000 births).
• The pilot site saw a dramatic decrease in event rates from 21.95 to 0 per 10,000 births.

Conclusions:

• Implementation of the comprehensive Newborn Fall Safety Bundle led to a significant reduction in newborn fall/drop events.
• The strategy proved effective in enhancing patient safety and preventing infant injuries within the health system.