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We aimed to develop a new scale for evaluating risks and preventive measures for in-hospital falls of newborn infants, from admission to discharge of the expectant mother. Our study was prepared in accordance with Failure Modes and Effects Analysis criteria. The risks and preventive measures for in-hospital falls of newborns were determined. Risk Priority Numbers (RPNs) were determined by multiplication of the scores of severity, probability of occurrence, and probability of detection. Analyses showed that risks having the highest RPNs were the mother with epidural anesthesia (RPN: 350 point), holding of the baby at the moment of delivery (RPN: 240), and transportation of baby right after delivery (RPN: 240). A reduction was detected in all RPNs after the application of preventive measures. Our risk model can function as a guide for obstetric clinics that need to form strategies to prevent newborn falls.
Operative and vaginal deliveries are among the most commonly performed procedures in hospitals. However, they have a lot of risks, and one may encounter some unpredictable and undesired complications at delivery. The risks for a newborn, including the risks for falling, start with the onset of labor. Falling incidents are particularly encountered at overcrowded delivery and education hospitals, and trauma incidents resulting from falling occur but unfortunately not put on the record. There are a limited number of publications in the literature regarding traumas resulting from in-hospital falls of newborns but there is no scale evaluating the risks and risk reduction measures [1–3]. In a previous study, 14 trauma cases were reported among 888774 deliveries. Trauma incidents of newborn babies resulting from falling were found to be 1.6 per 10.000. Seven of these incidents occurred when the mother holding the infant in a hospital bed or reclining chair fell asleep. Four of the cases occurred in the delivery room, 2 in the hallway while a nurse was wheeling a bassinette, and 1 from an infant swing. No deaths were reported. One patient sustained a depressed skull fracture and was transported to the regional children's hospital .
As a part of health care quality and insurance preoccupations some scoring systems have been developed for adult patients [4–7]. The first studies about falling risk were conducted by Morse and Hendrich [5–7], and after that different scoring systems and comparisons of their efficacy have been reported [4, 8–10]. Unfortunately, there are no scoring systems evaluating falls risk in children .
Our hospital has been accredited by the Joint Commission International (JCI) in 2006 and our intention is to improve the standards and care quality of the newborn and the mother. The Department of Gynecology and Obstetrics also provides neonatology service in Bayındır Hospitals since the foundation of the hospital. In line with the quality improvement services, we intend to prevent or minimize the risks of newborn falls, although we have not encountered any in-hospital falls in newborns till today. Failure Modes and Effects Analysis (FMEA) is a proactive technique that is most often used to identify and address problems before they occur [12, 13].
In an attempt to identify the risks beforehand, we aimed to develop a new scale for evaluating the risks and preventive measures for in-hospital falls of newborn infants, from admission to the discharge of the expectant mother and the baby, by using FMEA.
Our study was prepared in accordance with the FMEA criteria. A quality improvement team including an obstetrician, a neonatologist, nurses, and quality staff, who were involved in the process, was formed in order to determine the risks and preventive measures for in-hospital falls of newborns. The team worked for 20 hours at 10 sessions, each of which lasted 2 hours, between January and March 2009. Risks, which might be encountered throughout the process, were defined in accordance with FMEA. Firstly, the phases of delivery process, from hospitalization until discharge, were defined as follows: the process before the delivery took place, the delivery process, the transfer of the neonate, and the process of care. The preventive measures, their applicability and efficacy were reviewed. For the probable risks, scores of severity, probability, and predictability were calculated in accordance with the criteria of FMEA. Risk Priority Number (RPN) for each risk was determined by the multiplication of the calculated scores of severity of effect (S), probability of failure (PF), and probability of detection of an existing defect (P). (S × PF × P = RPN). “Bayındır Hospital Risk Evaluation Scale for In-hospital Falls of Newborn Infants” was developed (Figure 1). RPNs were determined twice: before and after the preventive measures. Additionally, the units and the staff that would be involved in the preventive measures were determined (obstetrician, nurse, cleaning personnel, etc.). The algorithm of the process is presented in Figure 2.
The risks determined for in-hospital falls of newborn infants are presented in Table 1. Scores of severity, probability, and predictability for all risks were calculated in accordance with FMEA scoring system , and precautions were determined. The preventive measures and the RPNs before and after the precautions are presented in Table 2.
Analyses showed that risks that have the highest RPNs are the mother with patient controlled analgesia (PCA) (RPN: 350 point), holding of the baby at the moment of delivery (RPN: 240), and transportation of the baby right after the delivery (RPN: 240). The other risky conditions were sorted as the patient standing up when the cervix was dilated greater than 5-6cm (RPN: 180) and the ones that might occur during the basic care of the baby (RPN: 180). After the preventive measures against these risks were implemented rescoring was performed. RPNs of all risks were reduced; the RPN of the mother with PCA dropped to 60, of the baby falling at the moment of delivery and transportation to 40 (Figure 3).
The interest in risk assessment tools and preventive measures for in-hospital falls has been gradually increasing in the recent years by the broad implementation of quality management tools and techniques in the hospitals. Up to date, a number of scales predicting the risks of hospital falls, especially for elderly patients have been developed [6, 7]. However, there is limited number of articles on newborn falling risk and prevention measures [1, 2].
Trauma cases resulting from falling are rare in newborns, but they may be fatal . As most of the cases are not put on the record, information on this issue is limited in the literature. Oregon patient safety commission drew attention on risk of falls to newborns of the mothers with PCA, and they enforced some preventive measures, and the commission indicated that there are a few studies in the literature about in-hospital falls of newborns .
Since the accreditation of our hospital, we have been working on quality management in all departments of our hospital. Within the scope of quality of service improvements, we wanted to take precautions against hospital falls, though no cases of newborn falls have been reported in our hospital till now.
As no scoring system was developed for newborn falls, we used the FMEA method used mainly in other sectors [14, 15] and have been implemented in healthcare in the last decade [16–18]. An FMEA study is not a traditional case control population study. It has some limitations originating primarily from the subjective scoring, while scoring the severity, probability of occurrence and detection, of the risks included in the RPN table. As FMEA, by development of a scale, increases the awareness and sensitivity to known and predictable risks, we think that it is superior to error proofing approach based only on clinical awareness [19–21].
We use the “Bayındır Hospital Risk Evaluation Scale for In-hospital Falls of Newborn Infants” in routine monitoring of the babies, along with the monitoring of the vital signs at 3-hour intervals. Besides the precautions taken, nursing support is provided to the babies with high risk scores. A problem encountered in our study was the over-estimation of risky cases, because the high risk threshold was set at a lower level in the scale. We will overcome this handicap by the evaluations performed at each 6 months as indicated in the algorithm, and we will implement new statistical support for our assessments.
Traumas resulting from falling inside the hospital are preventable. Newborn falls may be a serious problem particularly in obstetric clinics of overcrowded hospitals. In an effort to prevent newborn falls before happening, in this prospective study we developed, a scale in accordance with the FMEA. FMEA is a systematic method of resolving and detecting the problems before it starts and aims to properly evaluate a process or product for strengths, weaknesses, potential problem areas, or failure modes, and to prevent problems before they occur. Our results suggest that the most risky situations for newborn falls are the mother with epidural analgesia, holding of the baby at the moment of delivery, and transportation of the baby right after the delivery. After the development of the scale, we implemented all the preventive measures to overcome these risks in our hospital.
Each hospital where delivery operations are carried out, especially those with large patient numbers, must apply necessary precautions suitable for their hospitals to minimize the risks. We believe the scale we developed and the systematic application used in our study will contribute to the literature as to minimizing the risk of trauma of a newborn resulting from falling.
We think our study can function as a source for obstetric clinics that need to form strategies and clinic manuals to prevent trauma of a newborn resulting from falling. A work strategy for the prevention of in-hospital falls of the newborns should be determined and applied at each hospital.