The Unthinkable: Using Risk Resilience to Eliminate Newborn Falls

Purpose:
The Mother-Baby unit experienced newborn babies falling from their mother's arm. Within a 6 month timeframe, there were 5 incidents averaging 62 days between events. A nursing team was formed to analyze events, review literature, and design a safety program to eliminate newborn falls.

Significance:
Falls in the adult population are well studied however there is insufficient evidence for newborn falls. Prioritizing breast feeding and room-in strategies may potentiate newborn falls. Analyzing events is critical to identify adaptations, escalations, and hidden assumptions leading the event.

Strategy and Implementation:
The 5 falls occurred between the 2nd post delivery nights between 12 am to 9 am. Mothers were all found to have an average body mass index of 35, which led to inquiry regarding undiagnosed obstructive sleep apnea. The team determined the Berlin screening tool for obstructive sleep apnea lacked specificity and sensitivity. An improvement plan was developed to include safety huddles for mothers who were morbidly obese to plan frequent monitoring. Student nurses were used to round during the 2nd night to identify mothers with signs of fatigue. Students and nurses were taught how to recognize signs of fatigue and partner with the mother to safely place the baby in the crib. Education materials were developed to engage around second night syndrome and prevention strategies. A mother's nap time was initiated to promote proper rest. Stories were shared at the shared governance councils to highlight hidden assumptions and strategies to prevent further events.

Evaluation:
Post implementation of the safety program the labor and delivery unit has gone 146 days without an infant fall. There has been a shift among the care providers to a culture of safety and patient partnership in reducing harm.

Implications for Practice:
Nurses designed a safety programs resulting in no harm for vulnerable newborns. Providing nurses with the right resources, while taking immediate action, drives to 0 quality failures for all populations. Using risk resilience and a committed nursing workforce, the unthinkable can be prevented.