September 2014
Keeping Your Newborn Baby Safe from Falls While in the Hospital
Nursing; Obstrics and Gynecology; Pediatrics
No

 Many people who have experienced the birth of a newborn baby most likely have warm  thoughts of going to see the baby in the hospital and holding the baby for the first time. However, accidents can happen while families are bonding with their newborn baby while in the hospital. These accidents can not only harm the baby, but can cause emotional stress and guilt to the family member. Analysis of reports submitted to the Pennsylvania Patient Safety Authority from July 2004 to 2013 showed there were almost 300 newborn events reported to the Authority, including family members dropping their newborns after falling asleep, newborns slipping out of family members’ arms to the floor and newborns receiving bumps to their heads while being cared for by their families. More than nine percent of the events contributed to serious patient harm. Literature shows if families are more aware of the risks and hospital staff are monitoring more closely, these events may be prevented.

What is the definition of a fall for babies or children?

The American Nurses Association’s National Database of Nursing Quality Indicators (© 2014 Press Ganey Associates, Inc.) defines a baby/child drop as follows:

A fall in which a newborn, infant, or child being held or carried by a healthcare professional, parent, family member, or visitor falls or slips from that person’s hands, arms, lap, etc. This can occur when a child is being transferred from one person to another. The fall is counted regardless of the surface on which the child lands (e.g. bed, chair, or floor) and regardless of whether or not the fall results in injury. Falls in which a child rolls off a bed, crib, chair, table, etc. count as falls but are not classified as drops.

From Pennsylvania Data: Types of Newborn Injuries

Of the reported events, newborns fell in 272 events, the head was bumped or struck by an object in 14 events, and the newborn was found unresponsive in two events. Of these 288 events, 9.4 percent (n=27) were reported as Serious Events resulting in harm to the newborn.

Fall event types. Of the 272 newborn fall events reported, 55.1% (n=150) of the falls occurred after a family member fell asleep in a bed or chair. Real-life example below:

Event #1

Infant was sleeping on father’s chest in chair at side of bed; father fell asleep, and infant rolled to the floor facedown. Infant found crying in father’s arms. [Infant] returned to nursery for assessment by pediatrician. No apparent injury.

The second most common fall type, classified as "Newborn slipped out of arms while family member was lying, sitting, or standing."

Event #2

Infant fell from mother’s arms when mother bent over to pick something up from floor.

Serious Events
Event #3

In the first Serious Event, the mother was breastfeeding while sitting in a chair. The nurse checked on the mother 10 minutes later and found the baby blue and unresponsive. The mother was asleep. The newborn’s face was described as being completely covered by the mother’s breast. The newborn was placed on a ventilator and transferred to another hospital.

Event #4
In the second Serious Event, the newborn was brought to the mother for breastfeeding. The mother fell asleep with the newborn in bed. Sometime later, the mother called the nurse, who found the baby blue and unresponsive. Resuscitation efforts were unsuccessful.

What You Can Do: SAFE 

  • Some of the most harmful Pennsylvania events occurred while the mother was breastfeeding and fell asleep holding the child (causing suffocation or skull fractures). Do not be afraid to tell someone (nurse, family member) if you are too tired to hold your baby or need help breastfeeding.
  • All family and friends must be careful when handling the baby. Many of the Pennsylvania events happened because a family member fell asleep with the baby in their arms, the baby rolled off a sleeping family member’s lap, or the baby was dropped while being transferred to its hospital crib.
  • Findings show some of the most common maternal characteristics of why a newborn is dropped include the following: high level of fatigue, baby was breastfed, cesarean birth, and pain medication received in the last two to four hours.
  • Enjoy your new baby with family and friends. Make sure you and anyone handling the baby is fully awake and aware of how easy it can be to fall asleep while holding the baby. Don’t be afraid to ask for help.

For more information on preventing baby falls, go to the 2014 September Pennsylvania Patient Safety Advisory article "Balancing Family Bonding with Newborn Safety" at the Authority’s website at www.patientsafetyauthority.org.

©2017 Pennsylvania Patient Safety Authority