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Addressing In-Hospital "Falls" of Newborn Infants

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Background: During postpartum hospitalization, close physical interactions between mother and newborn facilitate attachment, breastfeeding, and relationship competence. The challenge during this time is to support these important interactions in the hospital while ensuring the safety of the newborn. A literature review indicated that newborn "falls" and drops—collectively referred to as falls—remains largely unaddressed. Experience of a sevenhospital system in Oregon offers a template for understanding how and why infant falls occur in hospitals and how to address the issue.

Identifying the Problem: For a two-year period (January 2006–December 2007), a query of a live voluntary event database yielded 9 cases of newborn falls (from 22,866 births), for a rate of 3.94 falls per 10,000 births.

Responding to Newborn Falls: A newborn falls committee made preliminary recommendations for interventions to reduce newborn falls, including (1) expanding the patient safety contract, (2) monitoring mothers more closely, (3) improving equipment safety, and (4) spreading information about newborn falls within the state and throughout the hospital system. For example, staff use the patient safety contract to improve awareness and prevention of falls. The mothers and significant family members are asked to review the safety information and sign the contract.

Conclusion: Newborns experience in-hospital falls at a rate of approximately 1.6–4.14/10,000 live births, resulting in an estimated 600–1,600 falls per year in the United States. Additional reports of rates of newborn falls are urgently needed to determine the true prevalence of this historically underreported event. Standardized evaluation and management guidelines need to be developed to aid the clinician in the appropriate care of newborns experiencing this infrequent event.

Document Type: Research Article

Publication date: 2010-07-01

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  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    David W. Baker, MD, MPH, FACP, executive vice president for the Division of Healthcare Quality Evaluation at The Joint Commission, is the inaugural editor-in-chief of The Joint Commission Journal on Quality and Patient Safety.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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