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.
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).
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.