Eliminating infant falls

Newborn Falls in a Large Tertiary Academic Center Over 13 Years

“…Some hospitals have developed nursing-led enhanced education, hourly rounding, and safety bundles as prevention strategies, with some success. 14,[16][17][18][19][20] In a study by Slogar et al 21 , investigators describe their experience with the surveillance of near misses in an effort to identify situations involving a high risk for a newborn fall. Highrisk situations described by Slogar et al 21 were identified by the nurses and included high levels of maternal fatigue, recent pain medication, and night shift hours.…”

Trends in rooming‐in practices among hospitals in the United States, 2007‐2015

“…12 Despite these and other barriers hospitals have faced, challenges to rooming-in may often be overcome by implementing creative solutions, such as described, and by explaining the benefits of 12,13,28 and providing educational materials on rooming-in to mothers and their families. 12,28 Despite the benefits of rooming-in, as it has become more of a common practice, safety issues have been raised 33 because of the potential concern for infant falls 34,35 and accidental suffocation. 36 Labor and delivery are arduous processes, often leaving the new mother exhausted.…”

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

“…* In the absence of science to guide them, pioneering clinicians defined the problem as the mother falling asleep with her newborn, designing targeted interventions for prevention. Using a quality improvement (QI) framework, 12,13,[16][17][18]20,25,28,29 clinicians implemented multiple commonsense solutions concurrently, † which, for the purposes of this article, are referred to as newborn safety bundles (NSBs). They included parental and staff education about safe sleep practices, ‡ frequent rounding, ‖ promotion of maternal rest, { parental signature on an infant safety pledge, # instruction to mothers to ask for assistance if feeling sleepy, ** reminder signage about safe sleep practices, † † identification of high risk mothers, ‡ ‡ and assignment or request for an alert individual to be present during nighttime feedings.…”

“…Although the goal was to ensure a sleeping mother was not holding her infant, the measure of success was the absence of an infant fall. 12,13,[16][17][18]20,25,28,29 In several studies, clinicians identified cases of sleeping mothers feeding or holding their infants when staff intervened before the infant fell. 7,13,16,18,21 The nuance that they had detected the mother after she fell asleep, instead of before she fell asleep (as intended), was not seen as an indicator of bundle failure.…”

“…12,16,18,25 The new mother had been informed not to sleep with her newborn, if only she had listened. Reinforcement about safe sleep practices was the most frequently recommended preventive strategy, 6,[11][12][13][14]17,21 and, so, for .1 decade, in the literature, it was declared that if the bundle was managed, this adverse event Lipkke et al 18 Ainsworth et al 13 Miner 25 Galuska 20 Hodges and Gilbert 17 Lahey et al 12 Hantske 16 Parental education was preventable. ‖‖ However, the data from the QI studies (Table 2) tell a different story.…”