Yes, that was my question too when I was asked to develop a presentation on newborn falls and environmental safety risks in postpartum and newborn areas. As you are aware, we have been encouraging new mothers to room-in to promote breastfeeding and mother-baby bonding through the Baby Friendly Hospital Initiative and our professional associations. Traditionally, new mothers stayed in their hospital rooms to rest after giving birth and only saw their baby at feeding times. Today, many hospitals no longer have a newborn nursery to encourage the mother-baby dyad to remain together. Policies have been changed to facilitate skin-to-skin contact and breastfeeding on demand. However, trying to care for a newborn leaves a tired mother little time for uninterrupted rest, increasing the risk that she may fall asleep while holding her baby. Recently, newborn falls have been recognized as a postpartum safety risk.

The 2013 National Database of Nursing Quality Indicators defines a newborn fall or baby drop as:

A fall in which a newborn, infant, or child being held or carried by a health care professional, patient, family member, or visitor falls or slips from that person's hands, arms, lap, etc. and can occur when a child is being transferred from one person to another. The fall is counted regardless of the surface on which the child lands (e.g., bed, chair or floor) and regardless of whether the fall results in an injury.1^(p3)

It is currently unknown what the actual rate of newborn falls is, and there is little research on the topic. There are several publications related to newborn falls, and after closely reading them, all seem to quote the same sources for their statistics. The first study examined newborn falls in a multihospital healthcare system over a 3-year period and determined the fall rate was1.6 falls per 10 000 births.2 Helsley et al3 later determined a newborn fall rate of 3.94 to 4.14 per 10 000 births and estimated that 600 to 1600 newborn falls occur in the United States annually. The Pennsylvania Patient Safety Authority concluded that newborn falls were the most common event affecting newborn safety according to its Pennsylvania Patient Safety Reporting System.4 It was found that 55.1% of falls occurred when a family member fell asleep, 27.2% occurred when the baby slipped out of the arms of a family member, and 17.7% of falls were related to the newborn falling from a hospital bed or incubator, dropped while being transferred, or slipped off a family member's lap.4 It was also established that the majority of newborn falls occurred between 24:00 and 07:00, with the highest percentage of falls occurring between 05:00 and 06:00.4 In total, 42.7% of newborn falls occurred on day 1 and 32.8% on day 2.4

The fall rate is reflective of newborn falls that occur in the postpartum areas. I could locate no literature that provided any information about newborn falls in the special care nursery (SCU) or the neonatal intensive care unit (NICU). I personally know of one newborn in the SCU who fell to the floor when a nurse's aide fell asleep in a rocking chair. I called my hospital to see whether there were any data for the 2 units and was informed there was no tracking of newborn falls as required for falls in other populations in the hospital and that a newborn fall would be included instead in an adverse event report. It is highly likely that the number of falls is underreported because of embarrassment, fears of repercussion, or not acknowledging the episode as a fall. I believe we need to recognize that we as providers, especially the neonatal providers, really have no idea about the scope of the problem outside the postpartum areas and have no understanding of how many "near misses" occur.

The risks may be somewhat different for newborn falls in SCUs and NICUs. Neonatal nurses do not have as many patients as the postpartum nurse who may be looking after a number of mother-baby dyads each in individual rooms. When the family comes to visit, it is the nurse who typically transfers the baby from the radiant warmer, incubator, or crib to the family member who is going to Kangaroo Care, feed, and/or hold the baby. The neonatal nurse is usually close by so that if the person holding the baby needs assistance or is sleepy, the nurse can gently take the baby and place him or her back in his or her bed. Also, critically ill neonates in the NICU are connected to monitoring equipment and intravenous pumps, making it very difficult for a parent to remove a baby on his or her own.

However, there are some units, especially those caring for a stable "grower feeder," that permit the mother and the father to remove the infant from the incubator or crib. Monitoring equipment may or may not be used on the infant, depending on the baby's age and acuity, and therefore the neonatal nurse may not be present when the parent(s) remove or place their baby back into the crib or incubator. There is where a safety issue can be raised. If you were the baby's nurse, did you double-check to be sure the crib rails were securely in place? That the incubator door was firmly latched, and all the portholes were closed? In the NICU, quick development of urgent situations that need multiple hands is not uncommon. Did anyone check that the NICU nurse who was called away urgently for another patient properly placed the radiant warmer wall/side rail back in place? Have you ever asked yourself, "Did I really latch that incubator door?" as you're walking away on the way to lunch? Have you seen the video of an older grower feeder kicking down the incubator door and falling out because it was not properly closed?5 Pretty scary stuff!

-M. Terese Verklan, PhD, CCNS, RNC, FAAN

Professor and Neonatal Clinical Nurse Specialist

University of Texas Medical Branch School of Nursing

Graduate School of Biomedical Sciences Galveston, Texas

References