Date of Graduation

Winter 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 E. Hebinck

Second Advisor

Jennifer H. Zesati


Problem: There has been a rise in In-hospital newborn falls following evidence-based practices such as breastfeeding and rooming that promote mother and baby bonding (Karlsson et al., (2021). U.S. hospitals have approximately 600 to 1,600 newborn falls annually (The Joint Commission [TJC], 2018).

Context: A San Francisco Bay hospital with a postpartum unit experienced three newborn falls as of 2023. The level III neonatal intensive care unit is a high-risk obstetric facility with more than 3,000 births annually. It comprises 21 hospital beds: 10 on the postpartum and 11 on the antepartum floors.

Intervention: Developing and implementing the “Pledge Form for Infant Safety form.” A nursing tool to educate postpartum patients on newborn fall prevention and reinforce commitment to safe sleep practices.

Measures: Qualitative information was gathered using pre-and post “Patient Education Surveys” and pre-implantation staff surveys. Pre- and post-implementation quantitative data derived from newborn chart audits using electronic medical records (EMRs).

Results: This project aimed to increase nurse-to-patient education by 10% and decrease the number of newborn falls. “Patient Education Surveys” demonstrated a 4.6% decrease in newborn fall prevention education compared to an 18.9% increase in EMR-documented nurse-to-patient education. No falls were reported from September to November.

Conclusion: Concluded with inconsistent data between “Patient Education Surveys” and EMR newborn chart audits. The findings present a need to assess a structured teaching approach for postpartum families. It may be beneficial to standardize the educational content and language, making it easier for patients to learn and recall the material.

Included in

Nursing Commons