Monson Sherry A, Henry Erick, Lambert Diane K, Schmutz Nancy, Christensen Robert D
Department of Women and Newborns, Intermountain Healthcare, Ogden, Utah 84403, USA.
Pediatrics. 2008 Aug;122(2):e277-80. doi: 10.1542/peds.2007-3811.
The fall of a newborn infant to the hospital floor is an error that has received little or no attention in medical publications. We sought to analyze the circumstances surrounding all such falls that occurred in an 18-hospital health care system during a 3-year period.
Information was located by using electronic and risk-management records. Demographic features, circumstances of the fall, and outcomes were tabulated for each event.
During the study period, 88774 live births occurred at the Intermountain Healthcare hospitals. Fourteen neonatal in-hospital falls were identified during this period (incidence estimate: 1.6 falls per 10000 births). Seven falls occurred when a parent, holding the infant in a hospital bed or reclining chair, fell asleep and the infant fell to the floor. Six of these 7 falls occurred between 1:30 am and 9:00 am. Four falls occurred in the delivery room, 2 in the hallway while a nurse was wheeling a bassinette, and 1 from an infant swing. No deaths occurred. One patient sustained a depressed skull fracture and was transported to the regional children's hospital. At hospital discharge, 13 of the 14 were reported to have a normal examination. No specific protocols for preventing in-hospital falls of neonates were in place.
If the incidence of a neonatal in-hospital fall in this study is representative, then 600 to 700 such falls occur annually in the United States. Relatively few scenarios explain the majority of falls. We speculate that the prevalence of this error could be reduced significantly by enacting programs aimed at eliminating or monitoring the most common circumstances under which these falls occur.
新生儿坠落到医院地面是一个在医学出版物中很少或几乎没有受到关注的失误。我们试图分析在一个由18家医院组成的医疗保健系统中，在3年期间发生的所有此类坠落事件的相关情况。
通过使用电子记录和风险管理记录来查找信息。将每个事件的人口统计学特征、坠落情况和结果制成表格。
在研究期间，山间医疗保健医院共发生88774例活产。在此期间共发现14例新生儿院内坠落事件（发病率估计：每10000例出生中有1.6例坠落）。7例坠落发生在父母抱着婴儿在医院病床或躺椅上睡着后，婴儿掉到地上。这7例中的6例发生在凌晨1:30至上午9:00之间。4例发生在产房，2例发生在护士推着婴儿床在走廊时，1例发生在婴儿秋千上。没有死亡病例。1名患者颅骨凹陷性骨折，被送往地区儿童医院。出院时，14例中有13例报告检查结果正常。当时没有预防新生儿院内坠落的具体方案。
如果本研究中新生儿院内坠落的发病率具有代表性，那么在美国每年发生600至700例此类坠落事件。相对较少的情况解释了大多数坠落事件。我们推测，通过制定旨在消除或监测这些坠落事件发生的最常见情况的方案，这种失误的发生率可以显著降低。
