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

To create a comprehensive newborn fall/drop event prevention and response strategy in the form of a Newborn Fall Safety Bundle and to reduce newborn fall/drop events across an eight-hospital health system.

A performance improvement initiative guided by the Plan-Do-Study-Act model.

A nonprofit health system consisting of one tertiary care center, three community hospitals, and four critical access hospitals. An increase in newborn fall/drop events was noted at one community hospital, with more than double the number of events being reported during fiscal year 2016 (five events) compared with fiscal year 2015 (two events). Injuries included skull fracture and hematoma, resulting in NICU admission and prolonged hospitalization.

Bedside registered nurses, educators, physicians, and nursing leadership representatives from tertiary, community, and critical access settings who formed a task force to identify and mitigate contributing factors, improve patient safety, and reduce newborn fall/drop events.

An evaluation of the problem was undertaken using root cause analysis and Pareto principles. Gaps were prioritized, and focus areas were identified. Evidence-based interventions were organized into a Newborn Fall Safety Bundle. Process and outcome metrics were tracked as measures of improvement.

Practice alignment with the Newborn Fall Safety Bundle was sustained at 90% or greater. Overall, the organization realized a 36% reduction in the newborn fall/drop event rate between fiscal year 2016 and fiscal year 2017. Rates declined from 6.66 to 4.06 newborn fall/drop events per 10,000 births. At the pilot site, newborn fall/drop event rates decreased from 21.95 to 0 events per 10,000 births over the same time period.

A reduction in newborn fall/drop events was observed after implementation of a comprehensive Newborn Fall Safety Bundle.