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


MSN project

First Advisor

Scout Hebinck

Second Advisor

Jennifer Zesati


Problem: This newborn fall prevention initiative was developed in response to an increase in the number of newborn falls at a Bay Area hospital on the postpartum unit. This hospital had gone six years without a newborn fall but by September of 2023 had three falls on the postpartum unit.

Context: The setting for this newborn fall prevention initiative is an urban, NICU level III Bay Area hospital that provides high-risk obstetric care. This Bay Area hospital has 247 licensed patient beds; 10 beds make up the postpartum unit and 11 beds make up the antepartum unit which serve as the postpartum overflow. This postpartum department is not a part of the Baby-Friendly Hospital Initiative (BFHI) but does promote rooming-in practice.

Interventions: A signed Pledge Form for Infant Safety was developed to create a sense of accountability on the parent’s behalf regarding newborn fall prevention measures.

Measures: The effectiveness of the signed Pledge Form for Infant Safety was measured using both objective and subjective data collection. Objective measures were collected from the review of patient electronic medical records (EMR) for the documentation of newborn fall education as well as the documentation of safety indicators related to newborn fall prevention. Subjective information was collected from postpartum nurses during the pre-implementation phase, as well as from newborn mothers during both the pre- and post-implementation phase of the study.

Results: The specific aim of increasing nurse-to-patient education by 10% and decrease the number of newborn falls in the postpartum unit from September to November 2023 was not fully met. There were no further newborn falls on the postpartum unit through November 2023, however subjective patient data and objective chart audits were conflicting in terms of nurse-to-patient education receipt.

Conclusion: The use of a signed Pledge Form for Infant Safety alone was not enough to increase nurse-to-patient education by 10% to meet the specific project aim. However, the addition of a required staff training and patient educational material (Pledge Form for Infant Safety) created an awareness of newborn falls and assisted in avoiding additional newborn falls on the postpartum unit.