Partnering with Parents: Preventing Infant Falls


Poster Presentation

Purpose for the Program

In December 2011, a report generated from the online-incident reporting system indicated that three infant falls (6.6 falls per 10,000 births) had occurred in 2011. Two infants falls (4.4 falls per 10,000 births) were reported in 2009 and no infant falls were reported in 2010. All incidents took place during the night shift and infant falls were due to the mother falling asleep. None of the newborns suffered serious injury. The mother–baby unit had just completed a project to increase exclusive breastfeeding and more infants (>70%) were rooming-in with their mothers. There was concern on the part of the staff that the new mother–baby care delivery model would be blamed for the increased rate in falls. The hospital had also recently purchased new beds that may have been contributory to the increased rate in falls because the side rails were not as high when the head of the bed was elevated.

Proposed Change

To fully evaluate contributory factors related to infant falls in the mother–baby unit and develop safety strategies to reduce/eliminate infant falls by instituting a Newborn Safety Partnering Agreement for Parents.

Implementation, Outcomes, and Evaluation

An increased rate of infant falls in the mother–baby unit prompted review to identify potential contributory factors, which included exhaustion of the mother after delivery, bedside rail position, too many pillows, timing and type of pain medication, cultural issues, and unsafe parental behaviors. A query was sent out to the NY Organization of Nurse Executives list serve, which requested any infant fall prevention programs that were successful. The query and literature review yielded minimal results. An infant safety checklist was developed to include awareness for potential falls. Based on feedback, the checklist evolved into a Newborn Safety Partnering Agreement for Parents and fall debrief tool to be used after a fall to immediately identify contributing factors. The premise behind the partnering agreement was to increase parents’ awareness of the potential of an infant fall beyond traditional patient education. The tool is used to educate and ask parents to partner with staff to keep their infant safe. A pilot to evaluate effectiveness was conducted. Minor changes to the tool and implementation of the agreement in the delivery room before delivery proved successful. Since the implementation of the Newborn Safety Partnering Agreement for Parents there have been no infant falls to date.

Implications for Nursing Practice

Implementation of a Newborn Safety Partnering Agreement for Parents on the mother–baby unit raises awareness to prevent infant falls and injury.