Hospitals work to prevent tragedy of dropped babies

Susan Wallace is used to sad stories.

An analyst for the Pennsylvania Patient Safety Authority, she reviews the reports that health-care facilities must regularly submit to the state, describing unfortunate events from bedsores to surgeries on the wrong knee.

As disturbing as it is to read about these incidents, she said, few have affected her as deeply as the one she came across a little more than a year ago.

A mother fell asleep while breast-feeding her newborn. "Sometime later," the hospital reported, "the mother called the nurse, who found the baby blue and unresponsive. Resuscitation efforts were unsuccessful."

The infant had suffocated.

Wallace, whose own daughter was pregnant at the time, cried when she read about the case. "It was so sad. Can you imagine?" She began to wonder how often newborns are accidentally harmed in hospitals when a new mother, exhausted after the ordeal of childbirth, drifts off to sleep.

Combing through records, looking back 91/2 years, Wallace discovered only one other tragedy in which a nursing baby was smothered. But she found nearly 300 incidents in which infants were dropped, bumped, or fell. Her findings were subsequently published in the peer-reviewed Pennsylvania Patient Safety Advisory.

The study is one of several recent attempts to gauge the scope of a problem that has been growing in the shadows.

Nationally, hospitals report between 600 and 1,600 newborn falls each year, figures that almost certainly fall short of the true number of incidents, said Ann Slogar, nurse manager of the Mother Baby Unit at MetroHealth Medical Center in Cleveland.

"This is a topic nobody wants to talk about," said Slogar, coauthor of a 2013 article about preventing newborn falls that was published in the journal Nursing for Women's Health.

Hospitals do not want to be seen as negligent, she said, and as long as the infant does not appear to be harmed, family members are usually too embarrassed to admit when they have dozed off and allowed a baby to slip out of their arms.

To improve the accuracy of hospital reports, in 2012, the American Nurses Association's National Database of Nursing Quality Indicators adopted a more precise definition of what constitutes a "fall" or "drop." The following year, reports increased by 46 percent.

Nursing experts believe these accidents are a perverse consequence of the national effort to promote a healthier, closer bond between mothers and their infants during the first hours and days of life.

Traditionally, American hospitals kept newborns in the nursery between feedings, allowing mothers to get some sleep. But for more than a decade, overwhelming data have shown that parents and babies benefit, both physically and emotionally, from "skin to skin" contact, breast-feeding on demand, and "rooming in"- that is, having the child remain in the hospital room with the mother as much as possible.

"The goal is to room-in as much as we can," said Alyssa Waite, nurse manager of couplet care and the women's inpatient unit at Lancaster General Hospital. "Quite frankly, a lot of moms and dads need a very short period of time where they can completely zonk out."

It is a difficult equation, Waite said, but ultimately, the baby's safety must take precedence: "If a mom is post C-section and has a lot of meds, and if the support people are just as exhausted as the mother, we sometimes need to separate."

The study Slogar conducted in Cleveland found that most of the "near misses," in which an infant was found in the arms of a sleeping adult, occurred between 3 and 6 a.m.

As part of the hospital's new strategy to prevent infant falls, nurses now make rounds more often during those hours, she said.

Across the country, similar efforts are underway.

In 2012, Abington Memorial Hospital, where about 5,000 babies are delivered each year, looked back over its records and found five infant falls in five years.

The hospital adopted new policies, training hospital staff to be more vigilant and teaching all new parents and their families basic rules about infant safety.

"In the past 18 months, we have had zero falls," said Lisa Kutz-McCauley, nurse manager of the hospital's Mother-Baby Unit and lactation services.

The nurses must strike a delicate balance, Kutz-McCauley said.

"If we see that a mother is groggy and there is no support person around, we take the baby to the nursery. And if the mother is attached to IVs or a Foley catheter, we don't encourage keeping the baby in the room, because if something bad happens, if the baby is choking, for instance, the mother can't get up out of bed."

The hospital tries to limit the time babies spend away from their mothers, however. Because, while the chances that an infant will be dropped in the nursery are close to nil, the environment poses other health risks.

"It is very stimulating in the nursery, there are bright lights, surgical procedures are being done, and it can be very loud with babies crying," said Kutz-McCauley. "Nursing and medical students are frequently in the room for teaching and assessments."

All that noise, light, and action has been shown to raise stress hormones in newborns.

"Sometimes caregivers have to deal with conflicting goals. We want to facilitate bonding between the new mom and her infant, while still keeping the baby safe from harm," Slogar said. "In the end, nurses have to do what they think is best in a given situation, which at times might mean placing the baby in the nursery for a short period of time."