however , they have a lot of risks , and one may encounter some unpredictable and undesired complications at delivery . the risks for a newborn , including the risks for falling , start with the onset of labor . falling incidents are particularly encountered at overcrowded delivery and education hospitals , and trauma incidents resulting from falling occur but unfortunately not put on the record . there are a limited number of publications in the literature regarding traumas resulting from in - hospital falls of newborns but there is no scale evaluating the risks and risk reduction measures [ 13 ] . in a previous study , 14 trauma cases were reported among 888774 deliveries . trauma incidents of newborn babies resulting from falling were found to be 1.6 per 10.000 . seven of these incidents occurred when the mother holding the infant in a hospital bed or reclining chair fell asleep . four of the cases occurred in the delivery room , 2 in the hallway while a nurse was wheeling a bassinette , and 1 from an infant swing . one patient sustained a depressed skull fracture and was transported to the regional children 's hospital . as a part of health care quality and insurance preoccupations the first studies about falling risk were conducted by morse and hendrich   [ 57 ] , and after that different scoring systems and comparisons of their efficacy have been reported [ 4 , 810 ] . unfortunately , there are no scoring systems evaluating falls risk in children . our hospital has been accredited by the joint commission international ( jci ) in 2006 and our intention is to improve the standards and care quality of the newborn and the mother . the department of gynecology and obstetrics also provides neonatology service in bayndr hospitals since the foundation of the hospital . in line with the quality improvement services , we intend to prevent or minimize the risks of newborn falls , although we have not encountered any in - hospital falls in newborns till today . failure modes and effects analysis ( fmea ) is a proactive technique that is most often used to identify and address problems before they occur [ 12 , 13 ] . in an attempt to identify the risks beforehand , we aimed to develop a new scale for evaluating the risks and preventive measures for in - hospital falls of newborn infants , from admission to the discharge of the expectant mother and the baby , by using fmea . a quality improvement team including an obstetrician , a neonatologist , nurses , and quality staff , who were involved in the process , was formed in order to determine the risks and preventive measures for in - hospital falls of newborns . the team worked for 20 hours at 10 sessions , each of which lasted 2 hours , between january and march 2009 . risks , which might be encountered throughout the process , were defined in accordance with fmea . firstly , the phases of delivery process , from hospitalization until discharge , were defined as follows : the process before the delivery took place , the delivery process , the transfer of the neonate , and the process of care . for the probable risks , scores of severity , probability , and predictability were calculated in accordance with the criteria of fmea . risk priority number ( rpn ) for each risk was determined by the multiplication of the calculated scores of severity of effect ( s ) , probability of failure ( pf ) , and probability of detection of an existing defect ( p ) . bayndr hospital risk evaluation scale for in - hospital falls of newborn infants  was developed ( figure 1 ) . additionally , the units and the staff that would be involved in the preventive measures were determined ( obstetrician , nurse , cleaning personnel , etc . ) . the algorithm of the process is presented in figure 2 . the risks determined for in - hospital falls of newborn infants are presented in table 1 . scores of severity , probability , and predictability for all risks were calculated in accordance with fmea scoring system , and precautions were determined . the preventive measures and the rpns before and after the precautions are presented in table 2 . analyses showed that risks that have the highest rpns are the mother with patient controlled analgesia ( pca ) ( rpn : 350 point ) , holding of the baby at the moment of delivery ( rpn : 240 ) , and transportation of the baby right after the delivery ( rpn : 240 ) . the other risky conditions were sorted as the patient standing up when the cervix was dilated greater than 5 - 6  cm ( rpn : 180 ) and the ones that might occur during the basic care of the baby ( rpn : 180 ) . rpns of all risks were reduced ; the rpn of the mother with pca dropped to 60 , of the baby falling at the moment of delivery and transportation to 40 ( figure 3 ) . the interest in risk assessment tools and preventive measures for in - hospital falls has been gradually increasing in the recent years by the broad implementation of quality management tools and techniques in the hospitals . up to date , a number of scales predicting the risks of hospital falls , especially for elderly patients have been developed [ 6 , 7 ] . however , there is limited number of articles on newborn falling risk and prevention measures [ 1 , 2 ] . trauma cases resulting from falling are rare in newborns , but they may be fatal . as most of the cases are not put on the record , information on this issue is limited in the literature . oregon patient safety commission drew attention on risk of falls to newborns of the mothers with pca , and they enforced some preventive measures , and the commission indicated that there are a few studies in the literature about in - hospital falls of newborns . since the accreditation of our hospital , we have been working on quality management in all departments of our hospital . within the scope of quality of service improvements , we wanted to take precautions against hospital falls , though no cases of newborn falls have been reported in our hospital till now . as no scoring system was developed for newborn falls , we used the fmea method used mainly in other sectors [ 14 , 15 ] and have been implemented in healthcare in the last decade [ 1618 ] . it has some limitations originating primarily from the subjective scoring , while scoring the severity , probability of occurrence and detection , of the risks included in the rpn table . as fmea , by development of a scale , increases the awareness and sensitivity to known and predictable risks , we think that it is superior to error proofing approach based only on clinical awareness [ 1921 ] . we use the  bayndr hospital risk evaluation scale for in - hospital falls of newborn infants  in routine monitoring of the babies , along with the monitoring of the vital signs at 3-hour intervals . besides the precautions taken , nursing support a problem encountered in our study was the over - estimation of risky cases , because the high risk threshold was set at a lower level in the scale . we will overcome this handicap by the evaluations performed at each 6 months as indicated in the algorithm , and we will implement new statistical support for our assessments . newborn falls may be a serious problem particularly in obstetric clinics of overcrowded hospitals . in an effort to prevent newborn falls before happening , in this prospective study we developed , a scale in accordance with the fmea . fmea is a systematic method of resolving and detecting the problems before it starts and aims to properly evaluate a process or product for strengths , weaknesses , potential problem areas , or failure modes , and to prevent problems before they occur . our results suggest that the most risky situations for newborn falls are the mother with epidural analgesia , holding of the baby at the moment of delivery , and transportation of the baby right after the delivery . after the development of the scale each hospital where delivery operations are carried out , especially those with large patient numbers , must apply necessary precautions suitable for their hospitals to minimize the risks . we believe the scale we developed and the systematic application used in our study will contribute to the literature as to minimizing the risk of trauma of a newborn resulting from falling . we think our study can function as a source for obstetric clinics that need to form strategies and clinic manuals to prevent trauma of a newborn resulting from falling . a work strategy for the prevention of in - hospital falls of the newborns should be determined and applied at each hospital .
we aimed to develop a new scale for evaluating risks and preventive measures for in - hospital falls of newborn infants , from admission to discharge of the expectant mother . 
 our study was prepared in accordance with failure modes and effects analysis criteria . 
 the risks and preventive measures for in - hospital falls of newborns were determined . 
 risk priority numbers ( rpns ) were determined by multiplication of the scores of severity , probability of occurrence , and probability of detection . 
 analyses showed that risks having the highest rpns were the mother with epidural anesthesia ( rpn : 350 point ) , holding of the baby at the moment of delivery ( rpn : 240 ) , and transportation of baby right after delivery ( rpn : 240 ) . 
 a reduction was detected in all rpns after the application of preventive measures . 
 our risk model can function as a guide for obstetric clinics that need to form strategies to prevent newborn falls .