​​​​While reviewing high harm events, a Patient Safety Authority analyst noted a report describing the near-death of a newborn after the mother fell asleep with the baby in her arms. The event prompted the analyst to determine whether any other similar events had occurred, and what she found was shocking: dozens of reports of newborns falling across the state, every year.

Because an individual facility may only experience one or two newborn falls annually, it was virtually impossible to measure the true scope of the problem without a broader perspective. The analysis—the largest one to date—brought light to an otherwise hidden and life-threatening issue. To further raise awareness of infant falls on a national level, the PSA collaborated with a facility to produce a safety video about the risks and how to protect against them.​