AWHONN Practice Brief Number 9: Prevention of Newborn Falls/Drops in the Hospital


•Consider all newborns at risk of experiencing in-hospital fall/drop events.
•Develop strategies to reduce variation in practice related to the prevention of in-hospital newborn fall/drop events.


According to the National Database of Nursing Quality Indicators (2016, pp. 2–3):

A newborn fall is a sudden, unintentional descent, with or without injury to the patient that results in the patient coming to rest on the floor, on or against another surface, on another person or object. A newborn drop is a fall in which a baby being held or carried by a health care 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 and regardless of whether or not the fall resulted in injury.

Within this practice brief, this occurrence will be referred to as a newborn fall/drop event.

In-hospital newborn fall/drop events may result in serious injury to the newborn and can cause emotional trauma to all involved including nurses, parents, and other hospital staff. The negative stigma often associated with in-hospital newborn fall/drop events may contribute to a decreased rate of reporting (Carr et al., 2019; Helsley et al., 2010). Annually, an estimated 600 to 1,600 newborns in the United States experience in-hospital newborn fall/drop events (Ainsworth et al., 2016). These events can be associated with maternal exhaustion (Bittle et al., 2019; Kahn et al., 2017; Lipke et al., 2018), breastfeeding (Kahn et al., 2017; Loyal et al., 2018), or miscalculation of the newborn’s location (Helsley et al., 2010; Kahn et al., 2017). Other factors associated with an increased risk of newborn fall/drop events include use of sedating medications, early morning hours, cesarean birth (Galuska, 2011; Miner, 2019), and second or third postpartum night (Galuska, 2011).

In 2018, The Joint Commission recommended the development and use of a validated screening tool to determine which newborns are at highest risk for experiencing fall/drop events. As of the time of this writing, no validated tool has been developed. Ethical concerns prevent prospective studies and randomized controlled trials related to newborn fall/drop events; therefore, available evidence is limited to quality improvement projects and retrospective chart reviews. These reports provide a valuable source of information on interventions to mitigate risks and prevent newborn fall/drop events. The strength of these interventions is enhanced as researchers report improved safety for newborns when similar interventions are applied in a standardized fashion (Ainsworth et al., 2016; Carr et al., 2019; Helsley, 2011; Helsley et al., 2010; Krening et al., 2016; Matteson et al., 2013; Miner, 2019).

The purpose of this practice brief is to provide recommendations for in-hospital, maternity and neonatal care teams. We recommend strategies to prevent in-hospital newborn fall/drop events, including nursing and parental/caregiver education, and tactics to standardize responses following a newborn fall/drop event.