In-Hospital Falls of Newborn Infants: Data From a Multihospital Health Care System

Monson, Sherry A; Henry, Erick; Lambert, D K; Schmutz, N; Christensen, Robert D.

doi:10.1542/peds.2007-3811

Cited by 62 publications

(92 citation statements)

References 15 publications

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“…67 The Oregon Patient Safety Review evaluated 7 hospitals that were part of 1 larger health system and identified 9 cases of newborn falls (from 22 866 births), for a rate of 3.94 falls per 10 000 births over a 2-year period from 2006 to 2007, which is higher than previous reports of 1.6 per 100 000. [68][69][70] It is not clear whether this higher incidence was attributable to an actual increase or better reporting. For hospitals transitioning to mother-infant dyad care (1 nurse providing care for both mother and infant) or separate mothernewborn care while rooming-in, it is important to communicate to staff that the same level of attention and care is necessary to provide optimal safety.…”

Section: Safety Concerns Regarding Rooming-inmentioning

confidence: 98%

Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns

Feldman-Winter¹,

Goldsmith²

2016

Pediatrics

163

110

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Skin-to-skin care (SSC) and rooming-in have become common practice in the newborn period for healthy newborns with the implementation of maternity care practices that support breastfeeding as delineated in the World Health Organization's "Ten Steps to Successful Breastfeeding." SSC and rooming-in are supported by evidence that indicates that the implementation of these practices increases overall and exclusive breastfeeding, safer and healthier transitions, and improved maternal-infant bonding. In some cases, however, the practice of SSC and rooming-in may pose safety concerns, particularly with regard to sleep. There have been several recent case reports and case series of severe and sudden unexpected postnatal collapse in the neonatal period among otherwise healthy newborns and near fatal or fatal events related to sleep, suffocation, and falls from adult hospital beds. Although these are largely case reports, there are potential dangers of unobserved SSC immediately after birth and throughout the postpartum hospital period as well as with unobserved rooming-in for at-risk situations. Moreover, behaviors that are modeled in the hospital after birth, such as sleep position, are likely to infl uence sleeping practices after discharge. Hospitals and birthing centers have found it diffi cult to develop policies that will allow SSC and rooming-in to continue in a safe manner. This clinical report is intended for birthing centers and delivery hospitals caring for healthy newborns to assist in the establishment of appropriate SSC and safe sleep policies.

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Section: Safety Concerns Regarding Rooming-inmentioning

confidence: 98%

Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns

Feldman-Winter¹,

Goldsmith²

2016

Pediatrics

163

110

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“…Estudos que tratam desse tema são raros e não foi encontrado na literatura nacional dados sobre frequência de queda na área neonatal em ambiente hospitalar. Nos Estados Unidos da América (EUA), um estudo (25) realizado em 18 hospitais de uma rede de serviço de saúde no período de 2004 a 2006, analisou a ocorrência de 14 quedas, tendo uma incidência estimada de 1,6 quedas por 10.000 nascidos vivos. Em Oregon, EUA (8) em sete hospitais foram observados nove casos de quedas de RN de 2006 a 2007, significando uma taxa de 3,94 quedas para 10.000 nascimentos.…”

Section: Discussionunclassified

“…As consequências para os RN associadas às quedas, encontradas em outros estudos (8,25) , abrangem desde nenhum ferimento, lesão menor como contusão, até lesões mais graves como traumatismo. Um estudo (2) menciona que não houve morte de RN resultante de queda no ambiente hospitalar, mas efeitos emocionais e psicológicos como a ansiedade e preocupação excessiva nas famílias decorrentes de quedas de bebês.…”

Section: Discussionunclassified

Queda De Recém-Nascido Internado Em Alojamento Conjunto

Torino¹,

Tsunechiro

Santos³

et al. 2016

Cogitare Enferm.

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RESUMO:O objetivo foi descrever as ocorrências de queda de recém-nascido em ambiente hospitalar. Estudo descritivo realizado em uma maternidade pública de ensino da cidade de São Paulo. As informações foram obtidas dos registros das Fichas de Notificação de Ocorrências e prontuários dos recém-nascidos que sofreram queda no alojamento conjunto, em 2013. Foram encontrados registros de quatro quedas não intencionais de recém-nascidos, indicando uma incidência de 11,36 quedas por 10.000 nascidos vivos. Três casos ocorreram no período noturno. As consequências para os neonatos abrangem desde nenhum ferimento até lesões moderadas como edema, hiperemia em têmpora e joelho, fratura em osso parietal e hematoma, que evoluíram em boas condições. Os achados acerca das circunstâncias das quedas podem auxiliar na compreensão desses acidentes e mostram a necessidade de implantação de estratégias de prevenção das quedas que proporcionem o cuidado multiprofissional em ambiente seguro e promovam a educação da mãe, familiares e profissionais. DESCRITORES: Acidentes por quedas; Segurança do paciente; Recém-nascido; Alojamento conjunto; Enfermagem obstétrica. QUEDA DE RECÉM-NASCIDO INTERNADO EM ALOJAMENTO CONJUNTO NEWBORN FALLS IN ROOMING-IN CAREABSTRACT: The objective of the study was to describe occurrences of newborn falls in the hospital environment. A descriptive study was conducted in a maternity of a public, teaching hospital in the city of São Paulo. Information was obtained from records of notification sheets and medical records of newborns who suffered falls in rooming-in care in 2013. Records of four newborn unintentional falls were found, showing an incidence of 11.36 falls per 10,000 live births. Three cases occurred during the night. Consequences for neonates range from no harm to moderate injuries, such as edema, hyperemia in temples and knees, fracture of the parietal bone, and hematoma that evolved in good conditions. Findings on circumstances of falls might help understand these accidents and show the need for implementation of fall prevention strategies that provide multidisciplinary care in a safe environment and promote education of mothers, families, and professionals. DESCRIPTORS: CAÍDA DE RECIÉN NACIDOS INTERNADOS EN ALOJAMIENTO CONJUNTO RESUMEN:El objetivo fue describir los eventos de caída de recién nacido en ambiente hospitalario. Estudio descriptivo, realizado en una maternidad pública de enseñanza de la Ciudad de São Paulo. La información fue obtenida de registros de las Fichas de Notificación de Eventos e historias clínicas de recién nacidos que sufrieron caída en el alojamiento conjunto, en 2013. Fueron encontrados registros de cuatro caídas no intencionales de recién nacidos, indicando una incidencia de 11,36 caídas por cada 10.000 nacidos vivos. Tres casos ocurrieron en el período nocturno. Las consecuencias para los neonatos incluyen: ningún evento, edema, hiperemia en la sien y la rodilla, fractura del hueso parietal y hematoma, que evolucionaron favorablemente. Los hallazgos sobre las circunstan...

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“…Falling incidents are particularly encountered at overcrowded delivery and education hospitals, and trauma incidents resulting from falling occur but unfortunately not put on the record. There are a limited number of publications in the literature regarding traumas resulting from in-hospital falls of newborns but there is no scale evaluating the risks and risk reduction measures [1–3]. In a previous study, 14 trauma cases were reported among 888774 deliveries.…”

Section: Introductionmentioning

confidence: 99%

“…No deaths were reported. One patient sustained a depressed skull fracture and was transported to the regional children's hospital [1]. …”

Section: Introductionmentioning

confidence: 99%

A New Scale for Evaluating the Risks for In-Hospital Falls of Newborn Infants: A Failure Modes and Effects Analysis Study

Abıke

Tiras

Dünder

et al. 2010

International Journal of Pediatrics

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We aimed to develop a new scale for evaluating risks and preventive measures for in-hospital falls of newborn infants, from admission to discharge of the expectant mother. Our study was prepared in accordance with Failure Modes and Effects Analysis criteria. The risks and preventive measures for in-hospital falls of newborns were determined. Risk Priority Numbers (RPNs) were determined by multiplication of the scores of severity, probability of occurrence, and probability of detection. Analyses showed that risks having the highest RPNs were the mother with epidural anesthesia (RPN: 350 point), holding of the baby at the moment of delivery (RPN: 240), and transportation of baby right after delivery (RPN: 240). A reduction was detected in all RPNs after the application of preventive measures. Our risk model can function as a guide for obstetric clinics that need to form strategies to prevent newborn falls.

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In-Hospital Falls of Newborn Infants: Data From a Multihospital Health Care System

Cited by 62 publications

References 15 publications

Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns

Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns

Queda De Recém-Nascido Internado Em Alojamento Conjunto

A New Scale for Evaluating the Risks for In-Hospital Falls of Newborn Infants: A Failure Modes and Effects Analysis Study

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