Tracking Near Misses to Keep Newborns Safe From Falls ppreventing patient falls is an important priority for hospitals nationwide. Recently an increasing focus has been placed on keeping newborns safe from falls, as reports indicate occurrences of infant falls can occur in the immediate postpartum period. Previous reports have identified factors present at the time of newborn falls (Galuska, 2011), yet there is little information Ann Slogar, MSN, BSN, RN, CNML Debra Gargiulo, BSN, RN Judy Bodrock, MHSA, BS, BSN, RNC on the prevalence of near misses, or how often risk factors for newborn falls are present in the postpartum period, and when these risks may be greatest. The purpose of this article is Abstract There is an increasing focus to keep newborns in the hospital safe from falls, as reports indicate that infant falls can occur in the immediate postpartum period. Previous reports have identified factors present at the time of newborn falls, yet there is little information on the prevalence of near misses or on risk factors present prior to the occurrence of falls. This article describes an innovative project to prevent newborn falls using information gathered about near misses. Most near misses occurred on the night shift, had the mother holding the baby and occurred an average of 52.6 hours after delivery. Collaboration among staff and patients is crucial to address risk factors present during near misses and to ultimately prevent newborn falls both in the hospital and at home. DOI: 10.1111/1751-486X.12035 Keywords fall near miss newborn newborn fall http://nwh.awhonn.org 2013, AWHONN 219
Ann Slogar, MSN, BSN, RN, CNML, is the manager of the mother/baby unit; Debra Gargiulo, BSN, RN, is a clinical nurse in the mother/baby unit; and Judy Bodrock, MHSA, BS, BSN, RNC, is the director of nursing for Women and Children; all authors are at MetroHealth Medical Center in Cleveland, OH. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: aslogar@metrohealth.org. to highlight a program developed to address near misses and to describe ways in which both health care providers and parents can work toward eliminating newborn falls. Background Our institution is a large, urban health care system serving high-risk and normal obstetric and newborn populations. It was anecdotally witnessed that mothers often fell asleep while holding newborns, placing them at high risk for an infant drop, or fall. It s well-known that postpartum mothers experience exhaustion after birth. Sleep deprivation and altered sleep patterns prior to labor, hormone vacillations for 9 months, analgesia and anesthesia and breastfeeding all contribute to postpartum fatigue. In the postpartum period, mothers need a quiet environment free of interruptions to aid in rest, as well as privacy in order to facilitate bonding with their newborn. While health care staff regularly perform patient rounds, it s often challenging to balance the mother s need for rest with frequent safety checks for mothers and newborns. Preventing patient falls is an important priority for hospitals nationwide Literature highlighting falls among newborns is a recent phenomenon. Adult falls are routinely reported for hospital quality and accreditation purposes. However, the reporting of infant falls has been less examined. One large study reported the incidence of 14 infant falls within an 18-hospital system where 88,774 babies were born annually (Monson, Henry, Lambert, Schmutz, & Christensen, 2008). Seven of the infants slipped to the floor when being held by parents seated in a recliner or in a bed. The majority of these falls occurred between 1:30 a.m. and 9 a.m. While none of the infants sustained serious injury, the study highlighted the lack of specific protocols to prevent in-hospital falls. If the incidence in this study is representative, it can be extrapolated that 600 to 700 infant falls occur annually in the United States. Helsley, McDonald, and Stewart (2010) found that these events are historically underreported and rarely do hospitals have standard evaluation and management guidelines when these falls occur. Box 1. Baby Safety Sheet Information Infant security strategies Identification policy Safe sleep tips: Baby back to sleep No holding baby while sleepy Request staff to help put baby back in bassinet Babies are not to be carried in hallways/ must be in bassinet One report described factors present when newborn falls occurred, and these included breastfeeding or breast/bottle-feeding, cesarean birth, second or third postoperative night, opioids for pain relief administered in the last 2 to 4 hours, significant other present in the room and mothers ages 18 to 28 (Galuska, 2011). While this information provides data on what happens at the time of a newborn fall, near misses inevitably occur, and it s equally important to know how often these same risk factors are present before the fall. Recognizing this, our nursing staff developed a multifaceted educational initiative involving both staff and parents, in an effort to prevent newborn falls in both the postpartum and the home setting. Initial Development Our initiative began by enlisting key staff members (i.e., unit champions ) on all shifts to help with staff education. Monthly meetings were held and the goal of fall prevention among newborns was introduced. A safety information sheet was then created by members of the nursing staff and approved by the risk management and practice councils within our organization. The safety sheet was shared electronically and during monthly staff meetings with all members of the nursing staff on the postpartum unit. The information was also shared in the outpatient obstetric clinic, the labor and delivery unit and the neonatal intensive care unit to ensure that patient education on newborn falls would begin prior to delivery and arrival on the postpartum floor. Formal in-services regarding newborn fall risks and safe sleep initiatives were delivered by an outside 220 Nursing for Women s Health Volume 17 Issue 3
for the nurse to document review of these materials. Nurses are expected to review and document this education every shift and any time a parent is found sleeping while holding the infant. Lastly, we also included our physician and ancillary unit staff (i.e., environmental services personnel, nutrition services and social services) to immediately report any occurrences where they observe a parent sleeping while holding an infant. A night shift initiative was implemented to enhance preventive strategies during this shift of highest risk speaker to members of the perinatal and pediatric nursing staff. Annual education for the nursing staff addresses and reinforces safe sleep principles of practice and patient education. Box 1 shows the information contained on the safety sheet that is reviewed with all patients upon admission to the postpartum unit. Both the patient and admitting nurse must sign the sheet and the patient is given a copy, while the other copy is included in the patient medical record. Illustrated signs containing this information are also posted on the bulletin boards in each patient room to remind patients in a friendly way about safe sleeping practices. Patients are given a laminated card provided by the county board of health to further illustrate the ABCs of safe sleeping. This card is reviewed upon admission and again immediately before hospital discharge. In order to ensure that this information is reviewed with all patients, we worked with our information services team to create a specific line item in the patient s electronic medical record Box 2. Risk Factors Assessed by Nurses High level of fatigue in the new mother Recent pain medication Night shift hours Prior near miss with this patient Woman > 2 days postpartum Woman with history of narcotic substance use and/or in methadone treatment program Program Enhancement Because there is scarce literature on actual risks for newborn falls, we wanted to be sure our safety initiative on falls encompassed all areas of risk. To proactively identify high-risk situations, unit champions on this project began safety rounds on all patients, and logged information if they observed a near miss. Certain patients were deemed to be at higher risk for a near miss if specific factors were present (see Box 2). A near miss was identified if staff witnessed a mother or family member asleep or sleepy while holding the newborn. We gathered information on the circumstances surrounding the near miss, such as time the event was witnessed, type of birth, how long it had been since birth, length of time since staff had last checked on the patient, who was holding the baby, where the baby was being held (i.e., bed or chair) and length of time since last pain medication. We used this information to revise the safety sheet and plan of care as needed and determine if additional interventions were required, such as more frequent checks by the staff, or additional educational initiatives for parents. Information was gathered on 64 near misses. Most (78 percent) occurred on the night shift between 11 p.m. and 7 a.m. (see Figure 1). For most cases (98 percent), the mother was the one holding the baby while sleeping in the bed. Sixty percent of near misses June July 2013 Nursing for Women s Health 221
Figure 1. Occurrence of Near Misses by Nursing Shift *Day shift is 7 a.m. to 3 p.m.; evening 3 p.m. to 11 p.m.; night shift is 11 p.m. to 7 a.m. were among patients who had vaginal birth, and the average length of time from birth to the witnessed near miss was 52.6 hours, indicating that these occurrences do not always occur immediately after birth. Some may occur up to 2 to 3 days after birth. It s stressed to patients that they will be more tired than they realize, and that falls can happen Th e average length of time from when a staff member had last checked on the patient to the time of the near miss was only 1.2 hours, suggesting that even frequent checks by staff may not be suffi cient to prevent infant falls. Th e average length of time since last pain medication administration was 5 hours (range 0.5 to 19 hours). Current and Future Enhancements Using information on these near misses, we incorporated additional enhancements to our newborn falls safety program. Data on near misses were discussed at a unit practice council meeting. As a result of this discussion, a night shift initiative was implemented to enhance preventive strategies during this shift of highest risk. Th ese included strategies to enable staff to check on patients without disturbing them. We found this could be accomplished by leaving patients doors slightly open at night so that staff can quietly enter without waking patients. We continue to try to balance this strategy with the need for patient privacy and ensuring a quiet environment outside patient rooms as well. Night shift staff members are being educated about ways to inform patients about the frequency of rounds being done during the night since we have identified that hourly rounds may not be enough. Patients are advised to turn on a light at night while feeding the baby. We have also implemented a quiet time in the early afternoon to give patients another period of uninterrupted rest. Members of the health care team are advised to schedule visits or activities with patients outside this quiet time in order to give patients time to sleep if needed. Multiple other departments were notified about quiet time before implementation to allow planning of their activities. Th ese departments included pediatrics, social services, nutrition, environmental services and the obstetric service. Visitors are not automatically restricted during this time. It s the patients choice to have visitors allowed during quiet time. Patients are informed 222 Nursing for Women s Health Volume 17 Issue 3
about the quiet time option and can choose whether or not they wish to participate. A patient survey was done as the quiet time initiative was begun, and 78 percent of patients indicated positive responses to the program. Patient education prior to discharge now also addresses safe sleep strategies to use at home (National Institute of Child Health and Human Development, 2013). Parents are educated about not putting items in a crib with the baby, not using heavy blankets or pillows, not co-sleeping with infant and making sure to put the infant in the crib when parents are feeling sleepy. Patients are advised not to stay in bed at night when feeding the baby, but rather to get up in a chair and turn on a light and/or the television to provide some stimulation. Nurses encourage parents to make sure they get rest at home whenever they can and to allow family members to help with household chores. Nurses remind new parents that cleaning and laundry can wait or be done by other family members. Patients are encouraged to nap or rest while the baby is sleeping. It s stressed to patients that they will be more tired than they realize, and that falls can happen. Lastly, all patients are given a laminated picture card with safe sleep tips. Conclusion As our program continues to expand, we are working toward developing a risk assessment tool to objectively assign patients a score based on how many risks for infant falls are present. Future research is needed to properly evaluate this tool and its use in the hospital setting. However, a validated tool would provide an objective method to assess newborn risk for falls and aid staff, patients and families in eliminating the occurrence of newborn falls, which remains a priority for all involved. NWH References Galuska, L. (2011). Prevention of in-hospital newborn falls. Nursing for Women s Health, 15(1), 59 61. Helsley, L., McDonald, J. V., & Stewart, V. T. (2010). Addressing in-hospital falls of newborn infants. Joint Commission Journal on Quality and Patient Safety, 36(7), 327 336. Monson, S. A., Henry, E., Lambert, D. K., Schmutz, N., & Christensen, R. D. (2008). In-hospital falls of newborn infants: Data from a multihospital health care system. Pediatrics, 122, e277 e280. National Institute of Child Health and Human Development. (2013). Safe to sleep public education campaign. Bethesda, MD: Author. Retrieved from www.nichd.nih.gov/sids/pages/sids.aspx In Practice It seems that barely a day goes by without a new drug being released or perhaps recalled. How can you stay on top of it all? Read Rx, a clinical practice column appearing three times a year in Nursing for Women s Health. It covers the latest developments in prescription and over-the-counter pharmacotherapeutics everything from the HPV vaccine to over-the-counter weight loss drugs, all to help you provide optimum care to your patients and to answer their questions. June July 2013 Nursing for Women s Health 223