Newborn Accidental Injuries Caused by Family Members in Hospitals Highighted in Pennsylvania Patient Safety Advisory to Raise Awareness

HARRISBURG, Pa., Sept. 15, 2014 /PRNewswire-USNewswire/ -- Almost 300 newborn events, including family members dropping their newborns after falling asleep, newborns slipping out of family members' arms to the floor and newborns receiving bumps to their heads while being cared for by their families are highlighted in an article from the September Pennsylvania Patient Safety Advisory released today to raise awareness for families and healthcare professionals. 

A query for events reported from July 2004 through December 2013 involving newborns less than 30 days old and in the care of their families identified 288 events. Of the reported occurrences, newborns fell in 272 events, newborns' heads were bumped or struck by an object in 14 events and newborns were found unresponsive in two events. Of these 288 events, 9.4% (n=27) were reported as Serious Events resulting in harm to newborns.

"Newborn falls were further analyzed and categorized into six types based on the event description," Susan C. Wallace, MPH, CPHRM, patient safety analyst for the Pennsylvania Patient Safety Authority said. "Of the two hundred and seventy-two newborn fall events reported, fifty-five percent of the falls occurred after a family member fell asleep in a bed or chair."

Wallace added that of the newborn falls, twenty-three were classified as Serious Events that resulted in harm to the newborn.

"Injuries reported to the Authority included various types of skull fractures," Wallace said. "In two other Serious Event reports, babies were accidentally suffocated after their mothers fell asleep while breastfeeding them. No fall or bump to the head occurred in those events."

Wallace added that the time of the newborn falls was also analyzed for this Advisory article. Of the 257 time-reported events, analysis showed that 58% (n=149) of newborn falls occurred between midnight and 7 a.m., with 19.5% (n=29 of 149) of these falls occurring between 5 and 6 a.m.

"Evaluation by staff of why a newborn fall occurred is key to examining the incident and finding ways to prevent future falls," Wallace said. "Studies show that healthcare facilities can make a difference in newborn events by implementing prevention methods such as family awareness, staff monitoring and education for both staff and families."

Wallace added that the Authority has made available to healthcare facilities an educational toolkit that includes posters for the clinical staff and patient rooms to raise awareness of baby falls. Also, consumer tips are available for patients and family members.

For more information about newborn baby falls in Pennsylvania go to the September Pennsylvania Patient Safety Advisory article, "Balancing Family Bonding with Newborn Safety," at www.patientsafetyauthority.org.

The Authority's 2014 September Advisory contains other clinical articles with toolkits for the healthcare provider to improve patient safety. Highlights of the 2014 September Advisory include:

• Robotic-Assisted Surgery: Focus on Training and Credentialing: Since 2005, Pennsylvania healthcare facilities have reported 722 events involving robotic-assisted surgery to the Authority. This article discusses how as professional standards develop, hospitals are responsible for developing training programs that adequately prepare the physician and surgical team to safely perform robotic procedures.
• Tracking Ambulatory Surgery Facility Cancellations and Transfers: Lessons Learned from an 18-month Collaboration: In 2012, 11 ambulatory surgery facilities (ASFs) in the northeast region of Pennsylvania worked in collaboration with the Authority to address the nurse-driven preoperative screening and assessment process in an effort to reduce day-of-surgery (DOS) cancellations and transfers. This article discusses the tracking tool used to help healthcare staff in developing appropriate solutions to reduce DOS occurrences and improve patient care. There is an educational toolkit available with this article.
• Patient-to-Patient Aggression in the Inpatient Behavioral Health Setting: Patient aggression in the inpatient behavioral health setting is a patient safety concern to patients and clinicians. Inpatient patient-to-patient aggression (48.8%) was the behavioral health aggression-related event most frequently reported to the Authority between January 1, 2012 and August 31, 2013. This article discusses a multidimensional assessment approach that incorporates patient-centered, staffing-centered, and environmental-centered considerations, a strategy that can be used to identify factors placing patients at risk or aggressive behavior.
• Results of the 2013-2014 Opioid Knowledge Assessment: Progress Seen, but Room for Improvement: In 2012, the Authority provided hospitals participating in the Pennsylvania Hospital Engagement Network adverse drug event collaboration with an 11-question opioid knowledge assessment tool to assess practitioners' knowledge about the use of opioids. In the winter of 2013-2014, the same assessment tool was distributed to reassess any changes in the year elapsed from the first assessment. This article discusses the results of the assessments in detail.
• Surgical Site Infection Prevention Utilizing Patient Screening and Decolonization: The PA-HEN SSI Prevention Collaboration: This article discusses collaboration among the Partnership for Patients, the Hospital and Healthsystem Association of Pennsylvania (HAP) and the Authority to reduce surgical-site infections. Standardized infection ratio aggregates decreased from 1.274 and 1.167 baseline to 0.797 and 0.735 postintervention. Forty hospitals participated in the collaboration. There is an educational toolkit available with this article.
• Wrong-Site Surgery Update: This article provides the quarterly update for the wrong-site surgery project. There were 14 reports of wrong-site surgery in Pennsylvania operating rooms (ORs) during the second quarter of 2014 and one belated report from a prior quarter. Despite the increase in reports of wrong-site surgery this quarter over the three previous quarters, the total for the academic year 2013-2014 is the lowest to date: 45. There is an educational toolkit available with this article.

For the complete 2014 September Pennsylvania Patient Safety Advisory, go to www.patientsafetyauthority.org.

SOURCE Pennsylvania Patient Safety Authority

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