Date of Graduation

Fall 12-15-2023

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Scout Hebinck

Second Advisor

Jennifer Zesati


Problem: In the past year, three separate newborn fall incidents occurred on the postpartum unit at Hospital X. This project aims to increase nurse-to-patient education on newborn fall prevention, thereby reducing the number of newborn falls on the unit.

Context: This quality improvement project was implemented on the postpartum unit at a hospital located in San Francisco County. At this hospital, the postpartum unit consists of 10 beds in postpartum and 11 beds in antepartum. Currently, there is no standardized method used by registered nurses to prevent newborn falls.

Intervention: The requirement for mothers to sign the Pledge Form for Infant Safety was implemented over the course of eight weeks. The pledge was intended for nurses to use when educating patients on newborn fall prevention. The pledge also serves as informal contract, reinforcing the mother’s role in ensuring the safety of their newborn.

Measures: The primary outcome measures include newborn fall rates and the percentage of mothers receiving newborn fall education.

Results: The results related to newborn fall education are conflicting. Data from the Patient Education Survey show that education on newborn falls decreased by 4.6%, while nurse documentation of education increased by 18.9%.

Conclusion: Overall, the data suggests a positive impact of the intervention on nursing practices, as evidenced by increased nurse documentation. Still, further investigation is needed to determine causes for the decrease in patient-reported education. To prevent future newborn falls, a comprehensive approach to newborn fall prevention is needed, taking into consideration the demographics of the patients involved.