According to the Centers for Disease Control and Prevention, the leading cause of nonfatal injuries in children age 0 to 19 are falls, and from 2004 to 2013 the Patient Safety Authority (PSA) noted a consistent increase in infant safety events—most of which were infant falls. Out of 272 infant falls in Pennsylvania, in 27 cases the infant suffered serious harm, and more than half occurred after a family member fell asleep while holding the infant. Fortunately, infant falls are preventable; literature shows that falls prevention strategies, such as rooming in without bed-sharing, safety rounds, and education for families and staff, can reduce the incidence of infant safety events.
After one hospital reported six infant falls (three in the Mother-Baby unit, two in the pediatric unit, and one in the emergency department) in fiscal year 2016, an interdisciplinary team was formed to address the issue, comprised of nurses, administrators, a physician, a performance improvement advisor, and an educator. This team attended a PSA webinar on successful strategies to promote infant safety and reduce adverse infant events and implemented them in their own hospital, including a staff education program to increase transparency and educate the staff regarding strategies to improve infant safety; safety agreement to engage patients in keeping their family safe along with patient education materials (safety posters, crib clings) to reinforce learning; and an infant safety video for families to view as part of their orientation to the Mother-Baby unit. The team worked with the marketing department to develop the video, which is shown to all parents within the first four hours of admission to the unit or if they are fatigued, as soon as they feel alert enough to view it; it is also available on demand through the hospital television network and on the hospital website, and patients are encouraged to have friends and family members view the video. Since this infant safety bundle was introduced in July 2016, there have been zero infant falls on the unit.
