Accidental, Falls, Infant, Newborn, Postpartum, Safety culture



  1. Knipper, Nora P. MSN, RN, NEA-BC
  2. DiCioccio, Heather Condo DNP, RNC-MNN
  3. Albert, Nancy M. PhD, RN, NE-BC, FAAN


Background: Parental fatigue rates after childbirth are high and may be associated with newborn drops that cause injury. Newborn drops and near-misses are potentially underreported due to parental embarrassment, shame, fear of reprisal, or guilt. Although newborn drops are rare, the leaders of mother-baby units need to enhance transparency of risk to assure a culture of safety.


Purpose: To describe components and outcomes of the What A Catch program, aimed at preventing newborn drops and addressing near-misses.


Methods: The What A Catch program was implemented in two hospital mother-baby units. The five components of the program included maintaining a respite nursery, using visual management, positively framing situational communication and actions after a near-miss, safe and appropriate staffing, and celebrating and transparently displaying program successes. Data were collected on near-miss event rates and caregivers and families provided postevent comments.


Results: The perinatal team embraced the program at both sites. Of 9,578 live births over 1 year, 202 near-misses or good catches were documented. Program leaders revise display the board multiple times per week.


Clinical Implications: Replication of this program is needed to determine if all five components are necessary to optimize a culture of safety. Future research may determine the scope of risk factors associated with newborn drops and near-misses, so that anticipated risk factors can be mitigated.