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Learning Session Abstract

“Keep Me Safe”: A Standardized Process for Reducing Harm from In-Hospital Newborn Falls/Drops

Kim, Maureen L. MD*; Donovan, Susanne RN; Magri, Eileen PhD RN; Christie, Dawn RN; Schulman, Helena RN; Akaydin, Lale MD*; Quintos-Alagheband, M. Lyn MD*,‡

Author Information
Pediatric Quality and Safety: March/April 2019 - Volume 4 - Issue - p e134
doi: 10.1097/pq9.0000000000000134
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Newborn infant falls/drops on the mother/baby unit are a challenging safety event that has not been widely reported in the literature. In March 2018, The Joint Commission issued a new advisory on newborn falls and drops in hospitals, outlining risk factors and safety recommendations. From 2011 to 2014, there were a total of 12 newborn falls/drops in our institution for a rate of 0.3/1,000 patient-days. Six (50%) demonstrated signs of mild acute injury on evaluation and imaging, translating to a baseline rate of 0.15 falls/drops with injury per 1,000 patient-days in our mother–baby unit.


The objective of this initiative was to implement a risk assessment tool to identify newborns at risk for falls/drop and develop a standardized process to reduce drops with injury. Our aim was to reduce newborn drops with injury from a baseline rate of 0.15/1,000 patient-days to 0.10/1,000 patient-days with stretch goal of zero.


An interdisciplinary team, consisting of nursing, pediatric hospitalists, neonatologists, residents, and quality specialist, identified a set of key drivers and a series of interventions (Fig. 1), which included implementing a risk assessment tool and creation of a standardized drop prevention bundle with increasing interventions based on the risk of drop.

Fig. 1.
Fig. 1.:
Key driver diagram. RCA, Root Cause Analysis.


The baseline rate for total newborn drops per 1,000 patient-days from 2011 to 2014 at our institution was 0.29/1,000 patient-days which decreased to 0.25/1,000 patient-days from 2015 to 2017. More importantly, our outcome measure of drops with injuries was at 0.15/1,000 patient-days from 2011 to 2014 and decreased significantly to 0.03/1,000 patient-days from 2015 to 2017 (Fig. 2).

Fig. 2.
Fig. 2.:
Newborn drops with injury per 1,000 patient-days. RCA, Root Cause Analysis.


Our “Keep Me Safe” program has been effective in reducing newborn inpatient drops with injury. We have identified family engagement as a key component to a successful drop prevention program, and we have developed a drop prevention “Key Card” to serve as a visual tool to assist nurses in educating parents about the risks of infant drops and how they can partner with us to prevent them.


newborn; inpatient; infant; drop

Copyright © 2019 the Author(s). Published by Wolters Kluwer Health, Inc.