Providence Health & Services' Women & Children's Program in Oregon has identified an under-reported incidence of newborn falls & drops. Within a two-year period 10 falls were reported on the UOR database with two skull fractures among the newborns. In analyzing the events there were 3 main categories-1) the most frequent is when the newborn is placed in the maternal hospital bed for breastfeeding or time together, the mother falls asleep, and the baby falls off the side of the bed to the floor 2) family members fall asleep on cots or in a rocking chair and drop the newborn as their arms relax in sleep 3) mother or family members are ambulating and trip or for some other reason drop the baby. Within the documentation parental reluctance to report the event is well documented, raising the issue of accurate prevalence rates. We have identified specific fall risk factors as extreme fatique from labor & delivery, high probability of medications effecting maternal responses, and the unusual characteristics of a hospital bed with the height and positions facilitating the newborn falling like a projectile when the head of the bed is elevated ~45 degrees with gaps in the side rails or no side rails depending on the model of the bed.

The issue has not been addressed as units do not routinely track and report these falls. When casually asked if a unit has newborn falls the response is usually a resounding no. But with more detailed questions about mothers falling asleep and dropping the babies, most units will remember some episodes. U.S literature has essentially no reports documenting the issue. UK has done substantially more work after a healthy newborn died in a fall from a maternal hospital bed in 2004 in London with extensive media coverage. UK midwives worked with UNICEF and WHO to develop policies and safeguards.

Current interventions being implemented in the 7 Oregon hospitals include: individualized maternal clinical assessments with results correlated to levels of supervision required when the babies go into the maternal beds (from the UK work), hourly nursing rounding, re-evaluation of pain & sleep medications on maternal preprinted order sets, parent safety contract reviewed and signed on admission educating about the no co-sleeping policy and the risk of falling asleep with your newborn in a hospital bed, documentation & communication of the individualized newborn fall prevention plan & re-evaluation for changing maternal clinical status, and re-design of the hospital maternity bed for increased newborn safety. We met with the US Stryker Design Engineer Team and anticipate a prototype bed with an integrated newborn bassinett by the fall of 2008.

We would like to see this aspect of patient falls addressed in the safety and quality monitoring happening nationally for adult falls. We are currently working with the Oregon Patient Safety Commission to alert all Oregon hospitals and have a planned manuscript submission to the Pediatrics Journal.