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

Abstract

Background: 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.

Methods: 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.

Results: 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.

Conclusion: 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.