Lessons Learned

Infants Fall Too

Case: A nursing mother fell asleep in the hospital bed and her newborn slipped out of her arms, falling to the floor. The mother had been on painkillers that made her drowsy. The infant was taken for a CT that showed a skull fracture. There were no family members in the patient’s room when the incident occurred.

In a preliminary search of CHPSO falls and perinatal events, approximately 35 in-hospital infant falls from 2014-2015 were due to the following:

  • The mother fell asleep with the infant in her arms
  • The nurse fell asleep while caring for the infant
  • Visitors dropped the infant because of improper handling
  • Visitors or hospital staff tripped over monitor chords, laptop or phone charging chords, or a baby warmer
  • The mother experienced a spasm and the infant fell off the bed

In-hospital newborn fall is defined as a newborn accidentally falling onto the hospital floor. While all in-hospital falls are a significant issue for hospitals, a newborn fall is not only a potential harm to the infant, but it may cause the caregiver to feel embarrassed and ashamed for dropping the infant.

The American Academy of Pediatrics (AAP) developed guidelines in 2011 for safe-sleep practices immediately after birth. Five recommendations to prevent in-hospital newborn falls include:

  1. supine sleep position,
  2. firm sleep surface,
  3. room-sharing without bed-sharing,
  4. avoiding alcohol and illicit drug prenatally and postpartum, and
  5. using Sudden Infant Death Syndrome (SIDS) risk-reduction recommendations by all healthcare providers starting at birth.

Promoting a safety culture for all patients, especially those vulnerable to falls, requires staff commitment to look over those who need extra attention. Although in-hospital infant falls are a rare occurrence, education for healthcare professionals and mothers can help minimize harm to infants.


Devitt M. (2012). AAP expands recommendations on SIDS and other sleep-related deaths. American Academy of Family Physicians. 85(9):918-923. http://www.aafp.org/afp/2012/0501/p918.html

Matteson T, Henderson-Williams A, Nelson, J. (2013) Preventing in-hospital newborn falls: a literature review. The American Journal of Maternal/Child Nursing. 38(6)359-366. http://www.nursingcenter.com/cearticle?an=00005721-201311000-00007#P106

Phalen A. G., Smolenski J. (2010). Newborn falls: Seeking solutions for a never event. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 39(s1), S46. http://dx.doi.org/10.1111/j.1552-6909.2010.01120_5.x