R E V I E W S & A N A LY S E S Balancing Family Bonding with Newborn Safety Susan C. Wallace, MPH, CPHRM INTRODUCTION Patient Safety Analyst Pennsylvania Patient Safety Authority Maternity units in healthcare facilities promote close interaction between families and their newborns to encourage the bonding process. However, newborns may be unin- tentionally injured while in the care of their families soon after birth. Exhausted family ABSTRACT members may not contemplate the possibility of a fall, bump to the head, or other An accidental injury of a newborn in the injury occurring while their newborn is placed in their care. care of family members soon after a The challenge for maternity units is to promote a close interaction between families hospital birth can cause emotional stress and their newborns while ensuring safety.1 Reports submitted by Pennsylvania hospitals and guilt. The challenge for hospitals to the Pennsylvania Patient Safety Authority through its Pennsylvania Patient Safety is to support bonding of newborns with Reporting System (PA-PSRS) over a nine-and-a-half year period were analyzed for events their families by encouraging breastfeed- that occurred while newborns were in the care of their families. ing, cuddling, holding, and touching while ensuring newborn safety. Analysis Falls were the most common events affecting newborn safety. The study and reporting of of reports submitted to the Pennsylvania newborn falls is a relatively new topic of concern; therefore, limited publications are avail- Patient Safety Authority from July 2004 able. Two published statistics of in-hospital newborn falls rates estimate nationally that to 2013 showed there were almost 600 to 1,600 newborn falls occur annually.1,2 Many of these falls can result in emotional 300 newborn events reported to the stress to the family as well as harm to the newborn. Literature shows that healthcare facili- Authority, including family members ties can make a difference in newborn events by incorporating prevention methods such dropping their newborns after falling as family awareness, staff monitoring, and education for both staff and families. asleep, newborns slipping out of family members’ arms to the floor, and new- METHODS borns receiving bumps to their heads Authority analysts identified 288 newborn events from PA-PSRS using terms associ- while being cared for by their families. ated with newborn safety (e.g., “fall,” “drop,” “bump,” “asleep,” “unresponsive”). The More than 9% of the events contrib- PA-PSRS database was queried for events reported from July 2004 through December uted to serious patient harm. Literature 2013 involving newborns ≤30 days old. Analysis of events focused on newborns who shows that healthcare facilities can were in the care of their families. make a difference in newborn events Analysis revealed that newborn events included falls, bumps to the head while being by incorporating prevention methods held or transferred, and events in which the newborn was found unresponsive. such as family awareness, staff monitor- Newborn falls were further analyzed and categorized into six types based on the event ing, and education for both staff and description (see Figure 1). Rates and times of falls were also analyzed and compared families. (Pa Patient Saf Advis 2014 with the rates and times noted in literature studies. Sep;11[3]:102-8.) RESULTS Types of Newborn Injuries Of the reported occurrences, newborns fell in 272 events, the head was bumped or struck by an object in 14 events, and the newborn was found unresponsive in 2 events. Of these 288 events, 9.4% (n = 27) were reported as Serious Events resulting in harm to the newborn. Fall event types. Of the 272 newborn fall events reported, 55.1% (n = 150) of the falls occurred after a family member fell asleep in a bed or chair. Examples are as follows: Upon entering the mom’s room, the nurse found a man crying and holding a crying infant. Mom stated she was sitting in the chair feeding the newborn when she fell asleep. The infant slid to the floor off of [the mom’s] lap. Mom stated the newborn’s Scan this code head was hit on the right side. with your mobile Infant was sleeping on father’s chest in chair at side of bed; father fell asleep, and infant device’s QR reader to access the rolled to the floor facedown. Infant found crying in father’s arms. [Infant] returned to Authority's toolkit nursery for assessment by pediatrician. No apparent injury. on this topic. Page 102 Pennsylvania Patient Safety Advisory Vol. 11, No. 3—September 2014 ©2014 Pennsylvania Patient Safety Authority Figure 1. Reasons Newborns Fell While under Family Care, July 2004 through stating that she was holding her baby December 2013, as Reported to the Pennsylvania Patient Safety Authority (N = 272) and fell asleep. X-ray revealed a skull fracture. 10 8 (3.0%) Infant fell from mother’s arms, land- 15 (3.7%) Family member fell asleep ing on right side of head and body. (5.5%) 15 in bed or chair Infant taken to NICU [neonatal (5.5%) intensive care unit]. Infant sustained Newborn slipped out of arms while family member was lying, bone skull fracture and small subdu- sitting, or standing ral hematoma. Newborn rolled out of hospital Bumps to the newborn’s head. In 14 re- bed or isolette ported events, the newborn’s head was 150 bumped while being held by a family Family member dropped 74 (55.1%) member. Circumstances in which the newborn while transferring (27.2%) newborn’s head was bumped included the Newborn rolled off family family member dropping or reaching for member’s lap a telephone or cell phone; bumping the MS14282 newborn’s head on a door, bed, or other Unknown object; and bumping the newborn’s head on an object overhead. Two events were reported as Serious Events. Examples of The following examples illustrate the sec- —— Family member dropped newborn these kinds of events with and without ond most common fall type, classified as while transferring: harm, respectively, are as follows: “Newborn slipped out of arms while fam- Mother rang call bell and stated that ily member was lying, sitting, or standing”: Mother was going to give the baby a she wanted nursing to come check the bath in the bathroom. The telephone Infant fell from mother’s arms when baby, as she dropped the baby on the rang. Mother went to answer the mother bent over to pick something floor. Mother had been feeding baby telephone and bumped the parietal up from the floor. while in bed. Mother stated she was area of the baby’s head on the door trying to get out of bed and the baby Mom brought baby to the nursery [in frame while carrying the baby to fell from her left arm. the morning]. Mom stated that she answer the telephone. CT [computed dropped the baby onto the floor while Mom called via call light to nurse tomography] scan of the head revealed changing breastfeeding position. Mom and asked nurse to come into her nondepressed fractures of the right was sitting in her bed. Baby fell and room. Nurse entered room with mom and left parietal bones. hit back of head. standing holding her baby next to Dad reported that he accidently chair, and [mom] stated to nurse, “I Other examples of newborn fall events are bumped baby’s head on plastic por- was getting up from the chair holding as follows: tion of bassinet. Baby cried briefly. the baby, and I dropped [the new- —— Newborn rolled off family mem- No open areas or bumps noted. born] on the floor”. ber’s lap: Newborn found unresponsive. Two Of the 272 newborn falls, 8.5% (n = 23) Mother reports that she was hold- Serious Events were reported in which the were classified as Serious Events that ing infant in her lap and the baby newborn was found unresponsive by the resulted in harm to the newborn. Injuries slipped from her lap onto floor. Nurse hospital staff and in which a fall or bump reported to the Authority included vari- assessed infant. Physician notified to the head did not occur. ous types of skull fractures (e.g., parietal and assessed infant. No injury visible. bone fracture), subdural hematoma, and In one event, the mother was breastfeed- —— Newborn rolled out of hospital bed subarachnoid bleed. Examples of reported ing while sitting in a chair. The nurse or isolette: Serious Events are as follows: checked on the mother 10 minutes Mother rang call bell to report infant later and found the baby blue and unre- Mother of [newborn] reported that had rolled off bed onto floor. Mother sponsive. The mother was asleep. The her baby had fallen out of her arms fed infant and placed [newborn] on her newborn’s face was described as being and onto the floor during the night, bed instead of in crib. No injury noted. completely covered by the mother’s breast. Vol. 11, No. 3—September 2014 Pennsylvania Patient Safety Advisory Page 103 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S The newborn was placed on a ventilator Table. Pennsylvania Rate of Falls While under Family Care for Newborns ≤30 Days Old and transferred to another hospital. YEAR NO. OF NO. OF LIVE BIRTHS RATE OF NEWBORN In the second event, the newborn was NEWBORN IN PENNSYLVANIA† FALLS PER 10,000 brought to the mother for breastfeeding. FALLS* LIVE BIRTHS The mother fell asleep with the newborn 2005 6 140,817 0.4 in the bed. Sometime later, the mother 2006 19 144,406 1.3 called the nurse, who found the baby blue and unresponsive. Resuscitation efforts 2007 28 144,717 1.9 were unsuccessful. 2008 21 141,345 1.5 2009 42 140,609 3.0 Pennsylvania Rate of Newborn 2010 34 136,726 2.5 Falls by Year 2011 26 136,646 1.9 The average length of stay in days for women who have given birth in all United 2012 35 135,811 2.6 States hospitals is 2.7 days.3 Of the 272 falls, 2013 51 133,653 3.8 85.3% (n = 232) occurred when the new- * Newborn falls reported to the Pennsylvania Patient Safety Authority born was younger than four days old. Of † Data obtained from the Pennsylvania Health Care Cost Containment Council these 232 newborn falls, 42.7% (n = 99) occurred on day one and 32.8% (n = 76) occurred on day two. See the Table for the Time of Newborn Falls or the mother several hours after the fall rates per year. The time of newborn falls was analyzed occurred only after noticing a change By taking the total number of falls from PA-PSRS event reports. Time is a in the newborn’s behavior or physical reported through PA-PSRS that occurred required field in PA-PSRS; however, the condition. One case narrative in the while a newborn (≤30 days old) was in time was reported as unknown in 15 of the literature quoted a mother as saying she the care of family members and using a 272 newborn fall events. Of the 257 time- was not going to tell anyone about the fall calculation of the total births reported reported events, analysis showed that 58.0% because she thought the newborn would to the Pennsylvania Health Care Cost (n = 149) of newborn falls occurred between be “just fine.”1 Containment Council,* a rate of newborn midnight and 7 a.m., with 19.5% (n = 29 of Fall definition. In the second quarter of falls was estimated per 10,000 live births. 149) of these falls occurring between 5 and 2013, the American Nurses Association’s Rate calculations ranged from 0.4 to 3.8 6 a.m. (see Figure 2). National Database of Nursing Quality newborn falls per 10,000 live births. Indicators (NDNQI) launched a revised DISCUSSION fall indicator as a clarification to its defi- * The Pennsylvania Health Care Cost Contain- Newborn Injuries nition to include a baby or child drop. ment Council (PHC4) is an independent state A 46% increase was observed in the agency responsible for addressing the problem Improving the safety of patients is rec- ognized as a priority in healthcare.4 PA-PSRS newborn falls data from 2013, of escalating health costs, ensuring the quality of health care, and increasing access to health care for Although falls and other injuries are after the new definition was published, all citizens regardless of ability to pay. PHC4 has primary concerns for hospitalized adults, compared with 2012. provided data to this entity in an effort to further there is a lack of newborn studies in the PHC4’s mission of educating the public and con- The NDNQI definition includes the taining health care costs in Pennsylvania. literature addressing newborn falls and following: “A fall in which a newborn, PHC4, its agents, and staff, have made no rep- other injuries that occur while the new- infant, or child being held or carried by resentation, guarantee, or warranty, express or born is in the care of their families. a healthcare professional, parent, family implied, that the data—financial, patient, payor, Even determining the true incidence member, or visitor falls or slips from that and physician specific information—provided to person’s hands, arms, lap, etc. This can this entity, are error-free, or that the use of the data of newborn events is challenging since will avoid differences of opinion or interpretation. families may be reluctant to report a new- occur when a child is being transferred This analysis was not prepared by PHC4. This born injury because of guilt or shame.5 from one person to another. The fall analysis was done by the Pennsylvania Patient Some events submitted to the Authority is counted regardless of the surface on Safety Authority. PHC4, its agents, and staff, bear describe how a fall was reported by a which the child lands (e.g. bed, chair, or no responsibility or liability for the results of the roommate of the patient, a staff member, floor) and regardless of whether or not analysis, which are solely the opinion of this entity. Page 104 Pennsylvania Patient Safety Advisory Vol. 11, No. 3—September 2014 ©2014 Pennsylvania Patient Safety Authority Figure 2. Time of Newborn Falls (Military Time), July 2004 through December 2013, when nurses found mothers either falling as Reported to the Pennsylvania Patient Safety Authority (n = 257) asleep or asleep while holding their newborns.8 TIME Bumps and unresponsive newborn events. 00:00 17 Events related to bumping the newborn’s 01:00 19 head or finding the newborn unrespon- 02:00 18 sive were not addressed in the literature. 03:00 19 Similar to newborn falls, exhaustion may 04:00 17 cause inattentiveness to safety when trans- 05:00 29 ferring or holding a newborn.1,2,9 06:00 17 Both fatigue-related events reported to 07:00 13 the Authority had similar maternal char- 08:00 6 acteristics associated with newborn falls, 09:00 5 including both mothers having fallen 10:00 10 asleep while breastfeeding. 11:00 8 12:00 10 RISK REDUCTION STRATEGIES 13:00 2 A literature review revealed that health- 14:00 4 care facilities have begun to recognize 15:00 7 newborn falls as a concern for potential 16:00 4 harm and have implemented initiatives 5 and adopted strategies to help reduce or 17:00 prevent newborn falls. 18:00 7 19:00 1 Newborn Falls Initiative 20:00 7 One hospital in Alabama was able to 21:00 11 bring their newborn fall rate to zero after 22:00 10 adopting a comprehensive falls preven- 23:00 11 tion program.9 After seven newborn 0 5 10 15 20 25 30 falls occurred in the postpartum unit MS14282 of Huntsville Hospital for Women and NO. OF NEWBORN FALLS Children, Huntsville, Alabama, from Note: Times reported were rounded to the nearest hour. No times were reported in December 2011 to July 2012, a committee 15 of the 272 total newborn falls events. was formed to examine each fall event, review the literature on newborn falls, the fall results in an injury. Falls in which providing statistics about newborn falls in and talk to other hospitals about their a child rolls off a bed, crib, chair, table, a hospital setting. Extrapolating data from experiences. etc. count as falls but are not classified the two studies suggests that the number The hospital implemented a comprehen- as drops.”6 of in-hospital newborn falls in the United sive falls prevention strategy in July 2012. States per year ranges from 600 to 1,600. The Authority launched a new falls The interventions addressed protocols for This is at a rate of 1.6 to 4.14 newborn reporting program in 2012 to standardize parent education, transport of newborns, falls per 10,000 live births.1,2 essential program components, including placement of newborns for sleeping, standardization of the definition for falls Both the Utah and Oregon studies review of maternal medications, assess- to ensure that all participating hospitals stated that the majority of newborn falls ment of environment and mother’s level identify, measure, and report falls in the occurred in the early morning hours of consciousness, and prevention of falls same manner.7 between 2 and 9 a.m.1,2 Another study during newborn feedings. monitoring near misses stated that 78% Newborn fall studies. A literature search Staff attended a required class on new- of newborn falls might have occurred on revealed studies in Utah and Oregon born falls and started charting with two the night shift between 11 p.m. and 7 a.m., Vol. 11, No. 3—September 2014 Pennsylvania Patient Safety Advisory Page 105 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S new tools to assess a newborn’s risk of this occurred, nurses were to thoughtfully An infant falls task force was formed from falling and perform a postfall debriefing. remove the newborn from the mother’s staff members of the Couplet Care Unit The staff educated parents on falls at arms and place the newborn into the bas- (postpartum unit) at Lancaster General admission, at the beginning of each shift, sinet.10 The author concluded that the Health’s Women and Babies Hospital, or as needed and instructed parents to effect of regular rounding on maternal Lancaster, Pennsylvania. After researching call before and after infant feedings so rest and newborn falls prevention is an the literature, the task force developed an that bedside rails could be raised and/or area requiring further research. informational sheet that outlines security lowered as an added precaution. Newborn In order to provide an environment and safety risk factors for the parents and falls information was also added to the conducive for rooming-in, maternal char- their newborn during the hospital stay. safety information sheet and was read acteristics have been studied. One study “We have always had a safety form that to the parents and signed at admission. found several common maternal factors we used for our parents upon delivery During the year following program imple- present when a newborn fall occurred. of their infant,” said Alyssa Livengood mentation, no newborn falls occurred. Another study gathered maternal informa- Waite, MSN, MHA, RN, nurse manager, tion on 64 near misses when a newborn Couplet Care/Women’s Inpatient Unit. Rooming-In without Bed-Sharing fall had the potential to occur (see “However, after researching this topic In an expansion of recommendations “Maternal Characteristics”). extensively, we felt compelled to change for a safe infant sleeping environment, the format and add content regarding risk the American Academy of Pediatrics Newborn Safety Information of falls and drops of newborns.” stated that rooming-in (i.e., sharing the for Families The staff reviews the informational sheet same room) without bed-sharing (i.e., Fatigue from the labor and delivery pro- with the mother and other family mem- sharing the same bed) is most likely to cess may lead to a newborn falling from bers within the first two hours of transfer prevent suffocation, strangulation, and the arms of a caregiver.1 At this exciting to the Couplet Care Unit, and then the entrapments that might occur when the time, families may not be aware that mother signs the form. “At the time we newborn is sleeping in an adult bed.10 they may fall asleep while holding their ask for the signature, we have educated Other safe infant sleeping recommenda- newborn while lying in bed or sitting in a the mother and any family in the room tions included placing the bassinet close hospital chair. with her as we provide our nursing care to the parent’s bed for feeding, comfort- to the family,” said Waite. “We find that ing, and monitoring of their newborn. Newborns may be brought into the bed for feeding or comforting but should be returned to their own bassinet when the MATERNAL CHARACTERISTICS parent is ready to return to sleep. The According to the reviewed literature, common maternal characteristic assessed after American Academy of Pediatrics does not a newborn fall included the following: recommend any specific bed-sharing situ- ——  High level of fatigue1 ation as safe. ——  Breastfeeding or breast/bottle feeding2 Helsley et al. described a “no co-sleeping” ——  Cesarean birth2 policy that was incorporated into nursing practice to ensure that the newborn was ——  Second or third postoperative night1,2 moved back to the bassinet by the parents ——  Pain medication in the last two to four hours1,2 and staff when the mother was preparing ——  Age 18 to 28 years2 for sleep, became drowsy, or had fallen ——  Prior near miss (e.g., nurses found mother either falling asleep or asleep while asleep.1 Hospitals may find it a challenge holding newborn)1 to balance the mother’s need for rest ——  History of narcotic substance use and/or methadone treatment program1 while promoting bonding and breastfeed- ing success.1,10 Notes 1. Slogar A, Gargiulo D, Bodrock J. Tracking ‘near misses’ to keep newborns safe from falls. Hourly rounding was incorporated into a Nurs Womens Health 2013 Jun-Jul;17(3):219-23. hospital’s falls prevention practice, with 2. Galuska L. Prevention of in-hospital newborn falls. Nurs Womens Health 2011 Feb- nurses intervening when finding a sleepy Mar;15(1):59-61. mother with a newborn in her arms. If Page 106 Pennsylvania Patient Safety Advisory Vol. 11, No. 3—September 2014 ©2014 Pennsylvania Patient Safety Authority this education must continue to reoccur Health and Services’ Newborn Safety is available on the Authority’s website at frequently throughout the family’s stay.” Information for Parents is available on the http://patientsafetyauthority.org/Edu Authority’s website at http://patient cationalTools/PatientSafetyTools/Pages/ The unit also posts an ABC Blocks visual safetyauthority.org/EducationalTools/ home.aspx. reminder on each newborn’s bassinet at eye level for mothers to see while they are PatientSafetyTools/Pages/home.aspx. in bed. It outlines safe sleeping habits for Postfall Huddle newborns, including sleeping alone. Other Safer Bed Design Evaluation by staff of why a newborn fall “safe sleep” education includes videos, Hospital beds utilized in the maternity occurred is key to examining the incident pamphlets, and single sheets picturing cor- suite were examined to determine if and capturing ways to prevent future falls. rect newborn placement in the crib. equipment could aid in newborn falls This has been essential in evaluating adult prevention. It was discovered that in other falls. Providence Health and Services uses Hospital staff in seven Oregon hospitals, an online version of the Newborn Fall part of Providence Health and Services, countries, such as the United Kingdom, Unusual Occurrence Report/Debrief Form also adopted an informational sheet titled bassinets are often mounted to the bed Post Event to capture additional details for Newborn Safety Information for Parents that frame, keeping the newborns within reach continued evaluation of factors involved outlines the factors that appear to increase of their mothers,11 whereas in the United in the event.1 This form is available on the risk of newborn falls during the post- States, bassinets are designed to be sepa- the Authority’s website at http://patient partum period.1 rate and independent units.1 safetyauthority.org/EducationalTools/ Research of bed manufacturers found no PatientSafetyTools/Pages/home.aspx. Challenges staff faced when using the informational sheet included receiving a modifications of hospital beds or bedrails parent’s signature at an emotional time that addressed designs that would prevent CONCLUSION when not all the information may be newborn falls, head entrapment, or suf- The birth of a baby can be one of the processed or understood and when other focation. Siderails on hospital beds may most joyous experiences for families. admission paperwork is being obtained.1 have openings large enough for a new- Dropping a baby after falling asleep or Other literature suggests providing parents born to fall to the floor when the mother caring for an infant when an accidental with written material prenatally and sched- is lying flat or when the head of the bed is injury occurs can be an emotional and uling meetings with childbirth educators, elevated by 45 degrees.1 life-changing experience for families, espe- who can help disseminate information cially if serious injury occurs. Literature Helsley et al. reported working with bed about newborn safety in a message that shows that healthcare facilities can make a manufacturers to develop safer mother/baby is consistent, clear, and standardized.8 difference in newborn events by incorpo- beds. A picture that demonstrates how a rating prevention methods such as family Lancaster General Health’s information newborn can fall out of a hospital bed awareness, staff monitoring, and educa- sheet and ABC Blocks and Providence tion for both staff and families. NOTES 1. Helsley L, McDonald JV, Stewart VT. 4. Longo DR, Hewett JE, Ge B, et al. The 8. Slogar A, Gargiulo D, Bodrock J. Track- Addressing in-hospital “falls” of newborn long road to patient safety: a status report ing ‘near misses’ to keep newborns safe infants. Jt Comm J Qual Patient Saf 2010 on patient safety systems. JAMA 2005 from falls. Nurs Womens Health 2013 Jun- Jul;36(7):327-33. Dec;294(22):2858-65. Jul;17(3):219-23. 2. Monson SA, Henry E, Lambert DK, et al. 5. Matteson T, Henderson-Williams A, 9. Ainsworth RM, Maetzold L, Mog C, et al. In-hospital falls of newborn infants: data Nelson J. Preventing in-hospital new- Protecting our littlest patients: a newborn from a multihospital health care system. born falls: a literature review. MCN falls prevention strategy. Presented at: Pediatrics 2008 Aug;122(2):e277-80. Am J Matern Child Nurs 2013 Nov- AWHONN Conference; 2013 Jun 16; 3. Centers for Disease Control and Preven- Dec;38(6):359-66. Nashville (TN). tion. Number and rate of discharges from 6. National Database of Nursing Quality 10. American Academy of Pediatrics. SIDS short-stay hospitals and of days of care, Indicators. E-mail to: Pennsylvania Patient and other sleep-related infant deaths: with average length of stay and standard Safety Authority. NDNQI definition. expansion of recommendations for a safe error, by selected first-listed diagnostic 2014 Jan 29. infant sleeping environment. Pediatrics categories: United States, 2010 [online]. 7. Pennsylvania Patient Safety Authority. 2011 Nov;128(5):1030-9. 2010 [cited 2014 May 9]. http://www.cdc. Falls event type decision tree for hospital 11. Paul SP, Goodman A, Remorino R, et al. gov/nchs/data/nhds/2average/2010ave2_ users [memorandum]. Program memoran- Newborn falls in-hospital: time to address firstlist.pdf dum no. 2012-06. 2012 Dec 20. the issue. Pract Midwife 2011 Apr;14(4):29-32. Vol. 11, No. 3—September 2014 Pennsylvania Patient Safety Advisory Page 107 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S LEARNING OBJECTIVES SELF-ASSESSMENT QUESTIONS —— Identify the types of events reported The following questions about this article may be useful for internal education and to the Pennsylvania Patient Safety assessment. You may use the following examples or come up with your own questions. Authority in which newborns were 1. According to events reported to the Authority, which of the following types of injured while in the care of their events occurred while newborns were in the care of their families? families. a. Falls, bumps to the head, and unresponsiveness —— Recognize the national rate of new- b. Falls, wrong treatment, and bumps to the head born falls. c. Wrong treatment, bumps to the head, and wrong expressed breast milk —— Recognize the types of newborn d. Unresponsiveness, wrong medication, and no newborn identification band fall events. e. Falls, no newborn identification band, and unresponsiveness —— Recall the most frequent time of day 2. What is the estimated national rate of newborn falls per 10,000 live births? a newborn fall event occurs. a. 2.5 to 6.54 —— Identify common maternal character- b. 1.5 to 7.03 istics assessed after a newborn fall. c. 1.6 to 4.14 d. 3.2 to 6.53 e. 1.2 to 3.24 3. Which of the statements below describes a situation that did not contribute to a newborn fall reported to the Authority? a. Falls occurred due to fatigue after a family member fell asleep in a bed or chair holding the newborn. b. Family members dropped newborns while transferring. c. Newborns slipped out the arms of a family member who was lying, sitting, or standing. d. Family members dropped newborns while walking in the hospital hallway. e. Newborns rolled off of a family member’s lap. 4. Which time was most frequently reported to the Authority as the time of newborn falls? a.10:00 b.14:00 c.19:00 d.05:00 e.01:00 5. Which of the following is not a maternal characteristic that may contribute to a newborn fall? a. High level of fatigue b. Age 18 to 28 c. Pain medication in the last two to four hours d. Natural childbirth e. Breastfeeding or breast/bottle feeding Page 108 Pennsylvania Patient Safety Advisory Vol. 11, No. 3—September 2014 ©2014 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 11, No. 3—September 2014. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2014 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. 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ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. 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