Editor’s Note: This month we are putting the spotlight on an especially vulnerable patient population– infants. In a slight departure from C&A’s typical newsletter article, we are sharing portions of a paper written by Nancy McLean, RN, BSN, MSHA, NHA, HACP, C&A Senior Consultant. Nancy recently became intrigued by the issue of newborn injury related to in-hospital falls and wrote this article to in part to raise awareness of an issue which is emerging in the literature. Nancy has coined the term “Cradle Safe” as encapsulating the need to focus on infant populations in our patient safety initiatives. As you read the article, be sure to click on the Initiatives link for a table of evidence-based practices that are addressing infant safety. Also provided is a bibliography of additional reading.
In 2008, Intermountain Healthcare, Salt Lake City, Utah bravely published an article on newborn falls to the floor in 7 of their hospitals (Monson, 2008). In 2010, Providence Health and Services in Renton, Washington, with 27 hospitals in the states of Alaska, Washington, Montana, Oregon, and California, published an article on the same topic using data collected from their hospitals (Helsley, 2010). Utilizing the data from these systems it is projected that the range of neonatal in-hospital falls annually in the U.S is between 600 and 1600.
The data collected demonstrated the most common cause was the mother or other caregiver falling asleep with the newborn in their arms and the child sliding to the floor from the hospital bed or chair. Other contributing reasons included, mother with seizure activity dropping baby while placing back into the bassinet, nurse transporting the newborn in a bassinet over an uneven surface, (entering an elevator), and mother dropping baby while standing and placing the baby into the bassinet or trying to place in the bassinet from the bed (Monson, 2008 and Helsley, 2010). The falls of newborns to the floor is distressing to all involved. Let’s make this a patient safety focus.
The cause of the incidence of newborn falls has not been clearly identified in the literature although several articles briefly touch on suspected causes. Matteson, et al., identifies the emergence of “rooming in” during the 1930’s and 1940’s. Cherry in a PowerPoint presentation lists mother/baby units and LDRPs as part of the background for the emergence of these incidents (Cherry, 2015). Mothers who leave other children at home to deliver a new sibling, mothers who are in labor for hours or undergoing induction for days, mothers who have a C-section are expected to maintain care of their newborns the same as mothers who experience a relatively easy labor.
On interview of several Managers and Directors of Maternal-Child units it was noted that as the change took place to eliminate nurseries there were few organizations that implemented a change in nursing practice for increased vigilance of mothers and newborns or changed nursing practice related to the safety of newborns in the “rooming-in” model of care.
The review of the literature revealed several safety initiatives to consider for elimination of this serious patient safety risk. Provided is a list of initiatives that serve as next steps in keeping newborns CRADLE SAFE.
Conclusions and Next Steps
On November 24, 2015, the Centers for Medicaid and Medicare in their “CMS News Blog” reported, “One of the most promising trends we’re seeing is the significant improvement in patient safety and decreased adverse incidents in the hospital setting. Thanks to several CMS programs that are improving patient safety in hospitals, such as the Partnership for Patients, from 2010 to 2013, there has been 1.3 million fewer hospital acquired conditions and 50,000 patient deaths avoided, leading to an estimated $12 billion savings in health care costs. This translates into a 17 percent reduction in patient harm nationally over the three-year period. This is a promising start, but we are committed to doing more.” The nursing focus on patient safety likely contributed to this reduction in harm. In hospitals with Obstetrical services, frequent rounding, at least hourly and more frequently when the newborn is not in the bassinet, parental education, and assessment of parental fatigue with emphasis on the mother’s fatigue can assist in elimination of newborn falls.
The available literature contains common threads that focus on prevention, one of those includes “safe sleeping” for the newborn, in its crib, bassinet or cradle (Moon 2013). Implementation of a CRADLE SAFE program is paramount to protecting our precious newborns. Establish a CRADLE SAFE program in your organization using the published and recapped information in your efforts on building a culture of safety and reducing harm in your organizations. Post and educate families on the American Academy of Pediatrics, “Safe Sleep Practices.” Provide families the American Academy of Pediatrics, “A Parent’s Guide to Safe Sleep.” If possible, implement as many of the recommended initiatives in Table 1 based on your organizations risk assessment.
Let’s all pledge to “Keep our Newborns Cradle Safe.”