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Case Study: Tiffany Mahuad Nu’10 GNu’13 BSN RN CLC RNC-MNN

How to prevent newborn falls? Change the beds.

Problem: An alarming rate of newborn falls.

Solution: The assistant nurse manager and I put together a committee. Every time a fall would happen, we would go back to the beginning—from the moment that the patient walked into the hospital. We would look through their chart, chart the course of the labor, and see what medication the mother was given. What time did the fall occur? In what setting? Was the patient feeding? Was she sitting down? Was she in her bed? And then we started to put the pieces of the puzzle together.
What that led us to was redesigning patient beds, particularly on the postpartum unit where falls were more prone to happen. The new beds had four side rails that were completely closed off. So if a mother was to fall asleep while breastfeeding her newborn and the baby happened to fall out of her arms, the baby wasn’t really going to go anywhere.
We also worked with the physicians to space out the amount of time we were giving narcotics to patients—making it every six hours instead of every four, and alternating that with pain relievers. That way they could still get quick pain relief, but not necessarily need to be on those hardhitting medications.
We actually wrote a protocol that still exists at our hospital that I think others have modeled, which is really an honor.

Tiffany’s story originally appeared on the Johnson&Johnson Nursing website as a “Get Inspired” profile. To view her complete profile as well as other relevant content around nurse-led innovation, visit