Newborns who room-in with their mothers achieve higher breastfeeding rates but may be at higher risk for falls. Most of these falls lead to no or only minor injuries, but serious injury is possible. In addition, such falls can be emotionally traumatic for parents, caregivers, and health care providers. After three falls in a two-month period, a hospital with a large population of opioid-exposed newborns devised an improvement project to reduce the incidence of newborn falls while maintaining optimal rooming-in.

The three-year project had three phases, with some variety in team members between the phases. After an interprofessional team performed a root cause analysis of one of the newborn falls at this facility, a quality improvement committee conducted in-depth chart reviews of all fall events. Members of an interprofessional team, including providers from the mother-baby unit, neonatal ICU, and pediatric and adolescent unit, developed and implemented parent education materials, a nursing risk assessment tool and an associated job aid and training module, and a standardized reporting system. The investigators aimed to reduce the newborn fall rate to fewer than 10 falls per 10,000 births, to go 365 days without a fall, and to eliminate fall-related injuries.

The root cause analysis and chart reviews cited the following as factors that might increase newborn falls: mothers' fatigue due to medication, delivery-related complications, the postpartum state, hesitancy to accept help, and being accustomed to cosleeping. Of 10 falls, nine were due to a parent falling asleep or slipping or tripping. Four falls involved prenatal opioid exposure. The newborn fall rate reached a high of 72 falls per 10,000 births in late 2016 and early 2017 and then decreased to 15.5 falls per 10,000 births during the three-year intervention period. Although the goal of fewer than 10 falls per 10,000 births wasn't met, the secondary goal of increasing days between falls to 365 was achieved. After the intervention, the authors note, there have been no fall-related injuries in three years.

The study was conducted at a single site, and the results may not be applicable to other settings. Prior to the intervention, there was no systematic monitoring of newborn falls or near misses, and because newborn falls are rare, variation analysis is difficult.