Eliminating Infant Harm: System-wide infant fall toolkit innovation

Purpose:
A system-wide team identified risk elements, designed innovative interventions, and implemented standard work to reduce infant falls in a large academic medical center. Learnings were spread across the system to impact outcomes.

Relevance/Significance:
Infant fall events are rarely reported and there is limited findings in the literature to guide evidence-based practice. One large healthcare system comprised of over 18 hospitals experienced 9 infant fall events in 2014. A 90-day course correction plan was implemented in all system-wide hospital obstetric departments to reduce the occurrence of fall events. This plan included explicit processes steps with outlined knowledge and accountability for process owners.

Strategy and Implementation:
The system-wide 90-day course correction plan used a grand rounds framework to review infant fall event characteristics. Nurse leaders worked with direct care nursing staff to identify key risk points in care delivery and the environment. An infant fall risk assessment was designed, piloted and implemented at the hospital with the largest number of births/highest rate of infant falls in the system. Direct care staff refined the risk tool prior to Electronic Medical Record (EMR) build, implementation and spread to the system. A patient education video describing infant fall risk and safety measures was filmed with direct care nurses. The video is shown to all delivered patients prior to the highest risk timeframe for infant falls. Transfer from the level of the maternal hospital bed to the standard height bassinet was a risk point. An innovative low bassinet was designed, piloted and beta tested with the unit awarded grant funds to replace the old bassinets with the new model.

Evaluation:
After implementation of the 90-day strong course correction the health care system reduced infant fall incidents from 9 to 1 over 5 months. 2015 system wide fall events include 3 infant falls to date; all of which occurred at sites where all standard work had not yet been implemented.

Implications for Practice:
Direct care nurses and nurse leaders developed a robust plan focused around innovative strategies, technology and accountability that led to system-wide improvement and learning. Direct care nurses now have confidence and resources to maintain a safe environment for healthcare delivery.