Newborn Falls Research Articles

In-Hospital Newborn Falls and Near Miss Events: A Need to Report.

This study aimed to evaluate the clinical characteristics of the neonates who fell in the maternity ward and identify the incidence of near miss events during the immediate postpartum period. The study consisted of two steps. The retrospective part included the evaluation of admissions due to the in-hospital newborn fall for 6 years. The prospective part included the assessment of the near miss events (any probability of falling of the newborn; either cosleeping or an incident with a possible consequence of falling of the newborn) in the postpartum clinic (<72 hours after delivery) for a period of 4 weeks. The details of the events and clinical outcomes were recorded. A questionnaire about fatigue was administered to mothers who experienced near miss event. Seventeen in-hospital newborn falls were recorded: 1.8 to 2.4/10,000 live births. The median age of the neonates when the fall occurred was 22 (16-34) postnatal hours. Fourteen events (82%) occurred between 10 p.m. and 6 a.m. All neonates who experienced a fall were discharged without any known adverse outcomes. Twelve mothers (71%) had experienced a near miss event before. In the prospective arm of the study, 67 out of 804 mothers (8.3%) were found to experience a near miss event (44/1,000 days of postpartum hospitalization). Thirty-two events (49%) occurred in the first postpartum day. Fifty-two events (78%) occurred between 10 p.m. and 6 a.m. Fifty-eight mothers (86%) had no companion. Sixty-three percent of the mothers expressed intense fatigue after delivery. In-hospital newborn fall may occur in the postpartum period, and near miss events should warn clinicians for a probable fall event. The nighttime shift requires more attention regarding the prevention of both the fall and the near miss events. Immediate postpartum mothers are needed to be observed carefully. · In-hospital newborn falls occurred mainly during the night shift.. · Nearly two-third of the mothers whose newborn was fallen experienced a previous near miss event.. · Any near miss event in the hospital was detected in 8.3% of mothers..

In-Hospital Newborn Falls and Suffocation Associated With Parental Drug-Related Fatigue.

In-Hospital Newborn Falls and Suffocation Associated With Parental Drug-Related Fatigue.

Multifaceted Intervention Reduces Newborn Falls in Mother–Baby Unit

According to this study: A multifaceted intervention can reduce newborn falls and injuries in a clinical setting with high rates of prenatal opioid exposure and a strong culture of breastfeeding and rooming-in.

Content Validity and Interrater Reliability of a Newborn Fall Risk Assessment Tool: KAnt Fall.

Newborn falls are a safety concern in the acute care setting. To our knowledge, a valid and reliable tool for assessing newborn fall risk has not been developed. To evaluate the content validity and interrater reliability of a tool for nurses to assess the fall risk of newborns in the acute care setting. Content validity was established using a modified Delphi technique with neonatal intensive care unit (NICU) nurses (n = 27). Item-level content validity indices and an average scale content validity index were calculated. For interrater reliability, pairs (n = 130) of NICU nurses simultaneously assessed multiple newborns using the tool, and an intraclass correlation coefficient was calculated. The initial tool had 28 items classified in 2 sections (newborn and caregiver variables). Fourteen items met predefined cut-off values for content validity. This resulted in the tool (KAnt Fall) having 7 items for assessing newborns and 7 items for caregivers. The intraclass correlation coefficient was 0.99 indicating excellent interrater reliability. The tool will help assist nurses in systematically identifying newborns at high risk for falls. This assessment will allow nurses to identify and implement timely preventive actions for hospitalized newborns at high risk for falls. Since this was a single-center study in 1 NICU, future research is needed in other hospitals and types of newborn settings (eg, labor and delivery and postpartum units). Further testing of KAnt Fall is also needed to establish additional psychometric properties.

A Longitudinal Study of a Multifaceted Intervention to Reduce Newborn Falls While Preserving Rooming-In on a Mother-Baby Unit

Newborn falls occur when newborns held by caregivers slip from hands or arms and land on another surface. Though injury is rare, The Joint Commission has highlighted newborn falls as a patient safety priority. One hospital sought to reduce newborn falls to fewer than 10 per 10,000 births, to achieve 365 days without a fall, and to reduce injuries from falls to zero, while preserving mother-baby rooming-in. An interprofessional quality improvement team developed and implemented prevention measures after three falls occurred in a two-month period. The team performed root cause analysis (RCA) of events and 10 in-depth chart reviews, and developed and implemented parent education materials, a nursing risk assessment tool and job aid, and a standardized reporting system. Outcomes were measured using statistical process control methods for rare events. In early 2017 the hospital's newborn fall rate increased to 71.8 falls per 10,000 births, with 3 falls occurring in a two-month period. RCA and chart review found sustained prenatal maternal opioid intake in 4 of 10 cases. Mechanism of fall differed by mode of delivery, with more drops by a sleeping caregiver following vaginal deliveries and falls due to maternal trips after cesarean deliveries. After interventions, the fall rate decreased to 15.5 per 10,000 births. Days between falls increased from a low of 9 days to a high of 467 days. No newborn injuries have occurred since early 2017. A series of interventions, including parent education, nursing practices, and attention to physical layout, was associated with reduced newborn falls and elimination of fall-related injuries while preserving rooming-in on a mother-baby unit with many opioid-exposed newborns.

In-Hospital Newborn Falls Associated With a Sleeping Parent: The Case for a New Paradigm.

A newborn fall to the floor from a sleeping parent's arms in the immediate postpartum period may result in a skull fracture, head bleed, and transfer to the NICU for observation. These harmful consequences galvanized frontline clinicians to prevent these tragic accidents, but, a decade later, they continue at a stubbornly low, persistent level. In this article, I suggest that a misunderstanding of sleep science may be a barrier to effective interventions. The science of sleep is presented to inform a new paradigm that would have greater potential of eliminating dangerous newborn falls.

A Newborn Fall Prevention Program

A Newborn Fall Prevention Program

Does every newborn need an imaging study after a fall? Case series and literature review

Objective This study examines the clinical and radiographic information from neonates who sustained a newborn fall (NF) to identify risk factors for the NF and the presence of skull fracture and intracranial bleed. In addition, published articles will be reviewed to provide data to assist in the evidence-based management of mothers after delivery and neonates after NF. Study design This is a retrospective chart review of neonates who sustained a NF in a level 4 NICU between 2016 and 2019. Results of imaging reports, maternal and neonatal clinical information, physical examination after fall, mode of delivery, time of day of fall, time between delivery and fall, feeding regimen, and maternal in hospital opioid use were recorded. Published reports containing imaging results and the incidence of skull fracture after NF were obtained by searching Pub Med from 2000 to 2019. Main outcome measures The main outcome of this study is to determine the presence and location of fractures and intracranial hemorrhage after a NF. Secondary outcome includes identification of clinical factors associated with the NF and presence of fractures. Student’s t-test was used for statistical comparisons. Results Twenty-one neonates sustained a NF and 83% were imaged by cranial CT. Skull fractures were identified by CT in 53% of neonates and ∼1/3 of infants had small intracranial hemorrhage. All infants were clinically stable and no neonate required neurosurgical intervention. Most NFs (73%) occurred between midnight and 8 AM and were associated with maternal sleeping while holding the infant. Conclusions Mothers should have increased monitoring and support especially the days after delivery from 11 PM to 9 AM to assess for maternal exhaustion and to prevent NFs regardless of opioid use. When indicated, low-dose rapid sequence CT scan rather than X-ray is preferred for evaluation of the neonate after a fall.

Ebelik Öğrencilerinin Doğum Eylemi Sırasında Karşılaştıkları Yenidoğan Düşme Riski ve Aldıkları Güvenlik Önlemleri

Objective: The purpose of this study was to determine the risk of newborn falls that midwifery students encountered during delivery and their safety precautions. Material and Methods: This study was designed descriptively. The population of the research consisted of 127 students who were attending in the 3rd and 4th grades of midwifery department of a university. The sample of the study consisted of 111 midwifery students. The data were collected by a questionnaire prepared by the researchers. The data were evaluated by using number, mean and percentage distributions. Results: It was determined that 11.7% of the students encountered the risk of newborn falls during delivery, 37.8 % always feared of newborn falls during delivery, and 26.1% observed health professionals encountering the risk of newborn falls during the deliveries. 28.8% of the students reported that they had a safety precaution in order to prevent newborn falls, and 68.7% of those who reported that they had a precaution said they tried to prevent the newborn fall by holding the infant tightly. Also, 81.1% of the students reported that they held the newborn from their feet during the delivery, supporting the body at the same time until the umbilical cord is cut. Conclusion: It was found in the study that more than one third of the students were afraid of slipping down the newborn from their hands during the delivery and approximately a quarter of the newborns encountered the risk of slipping down from the hands of health professionals in the deliveries observed by the students.

Newborn Falls in Pennsylvania

Despite increasing recognition of the potential risks associated with in-hospital newborn falls among health professionals, new parents are frequently unaware of the possibility of dropping their newborn, especially in the hospital. Although most newborn falls do not result in lasting harm to the newborn, they may necessitate additional health care services and cause stress to all involved parties. An analysis of reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) from January 2014 through December 2018 identified 318 events specifically related to newborn falls in the hospital following birth. An increase in the number and rate of serious newborn fall events reported to PA-PSRS was observed compared with a previous analysis by Wallace. Newborn falls were most commonly associated with a caregiver falling asleep (168 events, or 52.8%) and with newborn feeding (72 events, or 22.6%). Strategies to prevent newborn falls in the hospital include focusing efforts on providing support for exhausted parents during the critical time following the birth, offering periods of rest for new parents whenever they are tired, increasing the frequency of rounding when new mothers are breastfeeding, and promoting a midday break in visiting hours.

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

ObjectiveTo 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. DesignA performance improvement initiative guided by the Plan–Do–Study–Act model. Setting/Local ProblemA 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. ParticipantsBedside 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. Intervention/MeasurementsAn 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. ResultsPractice 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. ConclusionA reduction in newborn fall/drop events was observed after implementation of a comprehensive Newborn Fall Safety Bundle.

Newborn Fall–Drop Prevention and Response

The purpose of the Newborn Fall Safety Program was to create a comprehensive newborn fall–drop prevention and response strategy. An estimated 600–1,600 newborns experience an inhospital fall each year. Variation in risk identification, prevention, and response practices leaves newborns vulnerable to significant injury, such as skull fracture or even death. An increase in newborn fall–drop events was noted within one organization, with more than double the number of events being reported in Fiscal Year (FY) 2016 compared with FY 2015. Representatives from tertiary, community, and critical access settings united to identify and mitigate contributing factors, improve patient safety, and reduce newborn fall–drop rates. An evaluation of the problem was undertaken using root cause analysis and Pareto principles. Gaps were prioritized and focus areas identified. Evidence-based interventions were piloted and organized into a newborn fall safety bundle. The bundle was implemented within eight facilities and included patient–family and staff education tools, safety posters, a signed safety plan, intentional rounding, use of a feeding support pillow, and a postfall care algorithm. Process and outcome metrics were monitored. An audit tool was created to support accountability for bundle implementation. Newborn fall–drop events were tracked per the National Database for Nursing Quality Indicators definitions for baby fall–drop. Alignment with the bundle was sustained at or above 90%. Overall, the organization realized a 36% reduction in the newborn fall–drop rate across the health system from 6.66 per 10,000 births in FY 2016 to 4.06 per 10,000 births in FY 2017. The pilot site reduced newborn fall–drop events from 21.95 per 10,000 births in FY 2016 to 0 in FY 2017. Nursing practice implications include improved safety for vulnerable newborns through the use of the newborn safety bundle. Careful evaluation of the problem with interprofessional partners allowed the team to focus interventions. Use of the feeding support pillow protected newborns from injury. A strong safety message was reinforced through visual cues and a signed safety plan. Intentional safety rounding heightened vigilance to ensure key safety measures were in place throughout the hospitalization. The newborn postfall algorithm standardized care after a fall–drop.

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

The Centers for Disease Control and Prevention lists accidents (unintentional injuries) as the fifth leading cause of infant mortality. Data analysis from a multihospital system of inpatient family birth centers revealed fluctuations in newborn birth admission falls rates at times above the benchmark reported in the literature. We describe a multipronged approach to address an identified safety concern. The aim of the project was to decrease the rate of newborn falls during birth hospitalization. Despite applying multiple interventions described in the literature, newborn falls were not eliminated. In this quality improvement project, a nursing leadership team was convened to review the literature, identify current and ideal states, obtain stakeholder input, identify contributing factors, and agree on standardized interventions to prevent newborn falls. The project received exempt status from the institutional review board. Since we started the project in 2016, there was a downward trend in newborn birth admission falls in 2017; however, based on our variable data over the last 5 years and small numbers of falls, it is difficult to conclude that any one strategy or combination of strategies has been successful. Because falls from bed with the new mother were the most common types of newborn falls, interventions were focused; however, our falls rate for newborns never fell below comparable rates in the literature. More data are needed on effective interventions that can reduce the rate of newborn falls, especially those from bed while with the new mother. A comprehensive approach based on analysis of events and review of existing evidence are necessary first steps.

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

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

Preventing Newborn Falls and Improving Care for Postpartum Women and Their Newborns.

In their article, “Newborn Falls in a Large Tertiary Academic Center Over 13 Years,” Loyal et al1 report a retrospective review of newborn falls at a hospital birthing facility over a period of >10 years. This study is important because it reveals a problem that has recently garnered attention from The Joint Commission as being one that is not sufficiently understood.2 Birth is the most common reason for hospitalization in the United States, and although newborn falls are uncommon, it is a serious adverse event for patients, parents, and hospital staff when they do occur. Falls among hospitalized adults are ∼10- to 20-fold more common than falls among newborns, with the former having an occurrence rate of 3.56 falls per 1000 patient days, according to the authors of a recent study.3 In the study reported in this issue, the authors found a fall rate of 4.6 falls per 10 000 live births, or ∼2 falls per 10 000 patient days. Although the rate of infant falls during postpartum hospitalization is comparatively small, anyone who has experienced a newborn fall is well aware of the distress and potential harm that are caused when this does occur. We as clinicians and hospital administrators want to implement every step …

Newborn Falls in a Large Tertiary Academic Center Over 13 Years.

We sought to report the frequency of, circumstances surrounding, and outcomes of newborn falls in our hospital. We evaluated the impact of specific interventions on the frequency of newborn falls and the time between falls. We performed a retrospective study of newborn falls reported on our postpartum unit over a 13-year period. Demographic information and circumstances of falls were collected via an electronic event reporting system and medical record review. There were 63 633 births and 29 newborn falls, yielding an average of 4.6 falls per 10 000 live births (median: 2 per year; range 0-5 per year). Newborns who sustained a fall were exclusively breastfeeding (75.9%), 24 to 48 hours of age at the time of the fall (58.6%), and had first-time parents (62.1%). At the time of the fall, most newborns were with the mother compared with being with the father or both parents (65.5% vs 34.5%); in the mother's bed compared with being elsewhere, such as on a couch or chair, with a parent, or in the parent's arms (62.1% vs 37.9%); and feeding at the time of the fall versus not (79.3% vs 20.7%). All newborns were monitored after the fall, with no adverse outcomes. Despite interventions, we continued to see cases of newborn falls, although the overall trend revealed decreasing falls per 10 000 patient-days and longer time between falls over the study period. Newborn falls in our hospital are infrequent but continue to occur despite preventive efforts, highlighting the importance of continuous awareness and education.

Improvement of Newborn Fall Rates Through Policies, Education, and Promotion of Safe-Sleep Practice

The purpose of creating a newborn-specific “Risk to Fall Program” was to keep babies safe from falls and decrease this hospital’s rate of infant falls to below the national average. Another goal of this new program was to increase staff, parental, and family awareness. The hospital’s existing Risk to Fall Program was not specific to newborns, and data revealed that the prevalence of infant falls here exceeded four times the national average.

Variation in management of in-hospital newborn falls: a single-center experience

OBJECTIVE There are only 3 small case series in the literature that report on the management of in-hospital newborn falls (NFs), and recommendations are unclear. The authors performed a retrospective review to determine outcome and differences in management and to understand why management of NFs varies at their institution. METHODS All NFs occurring within the authors' institution over a 3.5-year period were reviewed. Post-fall management and outcomes of each incident were compared. RESULTS There were 24 NFs out of 40,349 deliveries (5.9 NFs/10,000 deliveries). The mechanism of injury was nearly identical in 22 of 24 falls (the newborn fell to the floor from a parent in a bed or chair), and physical examination findings were normal or benign in all cases. Unexplained management variation based solely on clinician preference was noted, including observation only (in 13 cases), skull radiograph (in 7), head CT scan (in 6), bone survey (in 4), and head ultrasound examination (in 1), with some babies having more than 1 study. Two babies had nondepressed linear parietal fractures diagnosed by skull radiograph, and 2 babies had small subdural hemorrhages diagnosed by head CT scan. All 24 babies had normal findings on examination at discharge. CONCLUSIONS There is a high incidence of nondepressed linear parietal skull fractures associated with NFs. However, since associated intracranial injury is uncommon, imaging studies may not be routinely performed. Neonatal intensive care unit admission, head CT, and neurosurgical evaluation are reserved for the rare baby with abnormal physical examination or neurological findings.

Using Nursing Pillows to Prevent Newborn Falls

Using Nursing Pillows to Prevent Newborn Falls

Preventing Newborn Falls While Supporting Family Bonding.

The Pennsylvania Safety Reporting System is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, birthing centers, and abortion facilities must file information on incidents and serious events. Safety Monitor is a column from Pennsylvania's Safety Authority, the authority that informs nurses on issues that can affect patient safety and presents strategies they can easily integrate into practice. For more information on the authority, visit www.patientsafetyauthority.org. For the original article discussed in this column or for other articles on patient safety, click on Patient Safety Advisories and then Advisory Library in the left-hand navigation menu. Language: en