A Comprehensive Newborn Falls Initiative One Year Later

Abstract

Paper Presentation Objective To reduce and prevent newborn falls at Huntsville Hospital for Women and Children. Design Evidence-based quality improvement project. Sample Mothers, infants, and staff at Huntsville Hospital for Women and Children. Methods The problem of newborn falls has been recognized in many hospitals; however, there are not yet evidence-based guidelines to direct hospitals in addressing this serious issue. From December 2011 to July 2012, there were seven newborn falls on the hospital's postpartum unit. In the spring of 2012, a committee formed to examine each fall event, review the literature on newborn falls, and talk to other hospitals about their experiences. Using this information, the committee created a policy on newborn falls prevention and developed education and tools for family members and staff. A comprehensive newborn falls initiative launched in July 2012, and 6 months later, staff members took anonymous surveys to evaluate implementation of the new protocol. Implementation Strategies The Policy and Procedure on Newborn Falls Prevention was implemented in July 2012 and addressed protocol for education of parents, infant transport, placement of infant for sleeping, review of maternal medications, assessment of environment and mother's level of consciousness, and prevention of falls during infant feedings. Staff members attended a required class on newborn falls and received further education from staff meetings, e-mails, and flyers. Two new charting tools (Newborn Fall Risk Assessment Tool and Post-Fall Debriefing Form) were created to address newborn falls. Staff members educate family members on falls at admission, the beginning of each shift, and as needed and instruct parents to call before and after infant feedings so that bed side rails can be raised and lowered as an added precaution. Information on newborn falls has also been added to the safety instruction sheet read to and signed by parents at admission; this sheet is posted on mirrors in patient bathrooms and on signs in rooms and included in the postpartum booklets and crib cards. Results The results of the staff survey indicate that 100% of staff members attended the newborn falls class; 95% read the newborn falls policy, and 89% the falls risk assessment tool at least once per shift. During the year following program implementation (July 2012 to July 2013), no newborn falls occurred. Conclusion/Implications for Nursing Practice Hospitals seeking to reduce and prevent newborn falls may learn from the experience of Huntsville Hospital and its newborn falls initiative.