Meghan Duck

To reduce Birth Center Fall Rate by 50% for FY 2018 compared to prior FY

By Meghan Duck, RNC-OB, MS, CNS


UCSF Benioff Children’s Hospital moved into a newly built facility, replete with new floor layouts, equipment, and processes, in February 2015 (FY2015).

♦       New practice instituted:  couplet care (“rooming in”)

•        Annual falls rate for the Birth Center more than doubled from FY 2015 to FY 2016 with a marked increase in maternal incidents after the move.

♦       Obstetrical (OB) falls reduction became a unit incentive goal for FY 2017. Maternal falls began to decrease.

•        No standardized and validated falls assessment tool specific to obstetrics exists. At UCSF:

♦       Past: Schmid & Little Schmidy tools

♦       Present: STRATIFY

These tools are not relevant to OB patients.

•        Community survey of other San Francisco Bay Area hospitals revealed use of various tools and inconsistent assessments.

PICO Question

Does the implementation and documentation of an Obstetric Safety Bundle reduce maternal falls incidence and decrease baby drops during hospitalization?


Concept:  Performance of bundled key interventions enhances safety & care continuity

Clinical Application

♦       Safety:  Rounding on postpartum patients & babies

♦       Physiologic:  Orthostatic vital signs assessment prior to 1st walk after giving birth

♦       Product:  Halo Bassinest® for 1st 24 hrs after C-section


♦       Staff:  Review orthostatic vital signs & evaluation of findings. Survey (pre/post) for risks / fall precautions.

Patient/family:  Address baby drop prevention by updating patient education materials


We did reduce our falls rate by 50% from FY 2016 to FY2017.  We have continued to reduce the falls rate by 30 % in FY 2018. 

Maternal falls and baby drop rates and count by year graph with a decrease in rates

Fall with injury rate & count by year graph with a decrease in rates


Patient / family teaching  –  Baby drop prevention 

  1. Updated pamphlet placed in all postpartum rooms; focuses on sleepiness

  2. Scripting developed for room orientation upon admission

  3. Parents sign fall prevention education form on admission

Safety Rounds  –  Every 2 Hours

  1. Assess/remediate potential causes for falling. Ensure call light/objects within reach. Address pain/other needs. Reinforce calling RN before walking.

  2. Promote safe sleep habits with rooming-in. Discourage co-sleeping,

  3. Ensure Halo Bassinest® in use during 1st 24 hrs after C-section

Staff teaching  –  Peer to peer & Tip sheets  & Practice update sheets 

  1. Orthostatic VS assessment prior to 1st walk post birth & PRN; how to take orthostatic VS (lying, sitting, standing) and evaluate findings

  2. Falls risk assessment Q shift & PRN changes in condition

Enhanced auditing – Falls & Rounding & Orthostatic VS taking

  1. Post Fall Huddle standard form updated with mother/baby items; colorized to match at-risk wrist bands & slippers


•        Fall incidents decreased by 30% in this current FY 2018. However, the fall rate remained static.

•        RN post-survey indicated increased understanding of expectations, prevention, and documentation. However, the response rate was low.

•        Bundle implementation success was attributed to:  multi-modal education for patients & staff; stakeholders’ buy-in early & often; and author availability for teaching & feedback.

•        Continue to keep abreast of any new, validated falls risk assessment tools specific to obstetrics which could be instituted in the Birth Center.

•        Regular updates to staff at staff meetings as well as clear and concise patient education is crucial to falls prevention in the Birth Center.