Joint Commission New Quick Safety Issue Addresses Preventing Newborn Falls and Drops

PUBLISHED: Mar 29, 2018
Relevant to: Ambulatory Care, Critical Access Hospitals, Hospitals

The Joint Commission has released Quick Safety Issue 40, addressing the prevention of newborn falls and drops. TJC uses Quick Safety Issues to raise awareness about important patient safety concerns.

According to TJC, while falls in adult populations are well-studied and researched, there is less attention given to falls in the newborn population. One study estimates that there are between 600 to 1600 newborn falls in US hospitals annually. TJC uses the National Database for Nursing Quality Indicators (NDNQI) definitions for newborn falls and newborn drops:

  • Newborn Fall: “a sudden, unintentional descent, with or without injury to the patient that results in the patient coming to rest on the floor, on or against another surface, on another person or object.”
  • Newborn Drop: “a fall in which a baby being held or carried by a health care professional, parent, family member, or visitor falls or slips from that person’s hands, arms, lap, etc. This 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 and regardless of whether or not the fall resulted in injury.”

There are many factors that can contribute to newborn falls and drops. Cesarean birth, pain medication use, second or third postpartum night when mothers are more tired and also breastfeeding - which can lead to increased drowsiness with ocytocin release. The challenge is balancing important goals such as skin-to-skin contact, frequent maternal infant interactions, and the promotion of breastfeeding with strategies to prevent newborn falls/drops.

In their Quick Safety Issue, TJC recommends several safety actions, including but not limited to:

  • Develop and use a standardized assessment tool that evaluates the risk of newborn fall/drop
  • Provide education to those identified at risk
  • Routine rounding with specific attention paid to mothers/caregivers who are noted to be drowsy
  • Promoting rest for the new mother
  • Using signage reminding of the importance of keeping the newborn in bassinette when mother/caregiver is sleepy
  • Cautioning mothers/caregivers from falling asleep while holding newbor.
  • Developing and implementing a standardized tool for reporting newborn falls
  • Providing post-fall/drop care to newborn
  • Developing and implementing a process for supporting mother/caregiver in event of a newborn/fall drop

Included with today’s notice are example polices related to newborn drops/falls. A link to TJC’s Quick Safety Issue is also provided.

Want to read the full alert and receive alert emails?

Browse Additional Alerts