EP16EO
Culture of Safety EP16EO
- Provide one example, with supporting evidence, of an improved patient safety outcome associated with clinical nurse involvement in the evaluation of patient safety data at the unit level.
- Patient outcome data must be submitted in the form of a graph with a data table
Example: Reducing the Percentage of Newborn Falls/Drops in the Greenwich Hospital Women’s and Children’s Department
Problem
In September 2017, the Greenwich Hospital (GH) Women’s and Children’s Department experienced a newborn fall. A mother attempted to get up from a rocking chair after she finished feeding her newborn to place him back in the open crib, and the newborn slipped to the floor without injury. This is deemed a newborn fall/drop. The American Academy of Pediatrics (AAP) and Joint Commission (JC) estimate that 600 to 1,600 newborns fall or are dropped annually in healthcare facilities in the United States; however, there is a limited focus on newborn fall prevention and an increased risk of serious harm in this at-risk population. “Understanding the potential increased risk of newborn falls and drops is a challenge in today’s fast paced health care environment. Utilizing principles of high reliability, including preoccupation with failure, a health care system should consider developing a process to help prevent newborn falls and drop for all infants under their care” (Joint Commission).
The GH Women’s and Children’s department comprises Labor and Delivery, Maternity, Neonatal Intensive Care Unit (NICU) and Pediatrics.
The one newborn fall/drop in GH’s Women’s and Children’s Department resulted in a percent of newborn falls/drops of 0.4% in September 2017. This is measured as the number of newborn falls/drops in GH’s Women’s and Children’s Department per live births, divided by the number of live births multiplied by 100.
Goal Statement
The goal was to reduce the percent of newborn falls/drops in Greenwich Hospital’s Women’s and Children’s Department.
Participants
Women’s and Children’s Newborn Fall/Drop Reduction Team
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Name/Credentials |
Discipline |
Title/Role |
Department |
Brenda Misuraca, MSN, APRN, NE-BC |
Nursing |
Director of W&C, IVF (at the time) |
Women’s and Children’s |
Patricia Basciano, BSN, RN, MNN |
Nursing |
Nurse Manger |
Women’s and Children’s |
Jeanne Van Sciver, RN, EFM-BC |
Nursing |
Senior Perinatal/ |
Labor & Delivery, NICU |
Loretta Jacob, MSN, RN, Inpatient OB |
Education |
Education Specialist |
Education |
Maureen Revel, BSN, RN, EFM-BC |
Nursing |
Patient Safety Nurse |
Women’s and Children’s |
Pamela Bruschi, RN, MNN |
Nursing |
Clinical Coordinator, Clinical Nurse |
Maternity |
Edna Fleming, BSN, RN, MNN |
Nursing |
Clinical Coordinator, Clinical Nurse |
Maternity |
Cathleen Scanlon, BSN, RN |
Nursing |
Clinical Resource Nurse, Clinical Nurse |
Maternity |
Sarah Stempien, BSN, RN |
Nursing |
Clinical Nurse |
Maternity |
Andrea Velasco, BSN, RN |
Nursing |
Clinical Nurse |
Maternity |
Theresa McIntosh, BSN, RN, EFM-BC |
Nursing |
Clinical Nurse |
Labor and Delivery |
Melissa Muller, BSN, RN, EFM-BC |
Nursing |
Clinical Nurse |
Labor and Delivery |
Description of the Intervention
October-November 2017
GH Women’s and Children’s Clinical Nurses Sarah Stempien, BSN, RN, Clinical Nurse; Edna Fleming, BSN, RN, Clinical Coordinator, Clinical Nurse; Pamela Bruschi, RN, MNN, Clinical Coordinator, Clinical Nurse; Andrea Velasco, BSN, RN, Clinical Nurse; and Cathleen Scanlon, BSN, RN, Clinical Nurse, met to review the fall event that had occurred on their unit. Along with Women’s and Children’s nursing leadership, they formed a team comprising clinical nurses, clinical nurse clinical coordinators, a nurse manager, an education specialist and a patient safety nurse to discuss a plan for reducing infant falls/drops.
The team reviewed the September 2017 infant fall data and the circumstances that led to the event. They reviewed literature regarding evidence-based infant fall/drop prevention strategies and creating a safe sleep environment.
The team developed safe sleep and fall/drop prevention strategies including:
- Education for parents on safe sleep practices for newborns
- Fall/drop prevention strategies including:
- Mothers who have taken pain medication and/or are tired should not hold their newborn in their arms if they are drowsy
- Do not walk in the hospital with your newborn in your arms, and use the crib to transport your newborn to and from the nursery
- Be mindful of younger children “holding” the newborn
Jacobs and Revel educated the Women’s and Children’s nursing staff on safe sleep practices to prevent newborn falls/drops.
The process for implementing the safe sleep, fall/drop prevention strategies included the following:
- Clinical nurses on Labor and Delivery will initiate safe sleep and infant fall/drop prevention strategies during the recovery period after birth.
- Upon admission to the Maternity Unit, the clinical nurses will ask the patient to sign a pledge stating their understanding of their responsibility in maintaining a safe sleep environment for their newborn.
- A thorough review of the practices and standards will be covered with the patient and significant other.
- Clinical nurses will round regularly to ensure parents are adhering to the recommendations and will log all near miss events in the event reporting database to track and trend for commonalities between any events.
- Signage will be placed in each room and a decal will be placed in the open crib to make parents and visitors aware of the risk of infant fall/drop.
The Newborn Fall/Drop Reduction Team developed a “Focus of the Month” education platform to include infant falls/drops to engage all team members to speak up and report any unsafe situation to reinforce the campaign for infant fall/drop reduction and safe sleep practices.
All interventions were fully implemented by the end of November 2017.
Outcomes
Women’s and Children’s clinical nurse involvement in the evaluation of patient safety data at the unit level led to a decrease in newborn falls/drops on the Women’s and Children’s Unit. There have been zero newborn falls/drops since the implementation of the safe sleep, falls/drops prevention program.
Evidence EP16EO-1, Greenwich Hospital Women’s and Children’s Department Percent of Newborn Falls/Drops