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According to the Centers for Disease Control and Prevention (CDC) falls are the leading cause of non-fatal injuries for all children ages 0 to 19 years.  A recent study (Monson, et al., 2008) reported a newborn falls rate of 1.6 per 10,000 births.  The IOM (Institute of Medicine) and the JC (Joint Commission) recognize patient safety problems, mandate the need for improvement and encourage development of safety systems. In 2006, the JC issued National Patient Safety Goal, 09.02.01, focusing on the reduction of falls.  In response, hospitals and long term facilities implemented falls reduction programs for adult and elderly populations.  However, there is little evidence newborn centers monitor falls because of their rare incidence.  The majority of newborn falls are preventable.  Newborn falls are classified as accidental and a result of environmental factors or errors in judgment.  Injuries associated with a newborn fall, most often minor, range from bruises confined to the head or subgaleal hematomas to depressed skull fractures.  Newborn centers have a responsibility to create and promote an environment of safety.  Approaches to injury prevention must begin at birth.  A proposed plan to meet this challenge is the establishment of an innovative newborn safety program.  The program is composed of 3 steps: (1) a robust process for empirically assessing the newborn’s risk of falling, resulting in targeted interventions aimed at reducing risk; (2) specific policies/clinical guidelines for assessment and reassessment of a newborn post fall with a method of documentation; and (3) a system for evaluating the effectiveness of the program.  A newborn fall can occur in the labor and delivery suite, postpartum unit, well newborn unit, newborn intensive care unit (NICU) and during transport.  Each unit or situation must thoroughly assess their environment as well as the clinical practice of the care providers.  Assessments then generate strategies and measures intended to prevent a newborn fall.  Some examples include: bed heights set at the lowest position; equipment cords removed from walkways; using protective measures during weighing on a scale, or in a swing or bouncy seat; covering gaps between elevator and floor to prevent crib/transporter wheels from falling through; use cribs for transfers instead of carrying infants; establish a system of frequent checks or the presence of a “sitter” to monitor medicated or sleepy parent/s who are holding their newborn.  After a fall, questions often emerge focusing on how frequently should the newborn be assessed, what diagnostic tests performed, what is communicated to parents and other providers and documented in the medical record.  Specific protocols provide a standard of care practiced consistently across all units.  The final steps in the safety program is educating staff and families on risk reduction strategies and constructing a surveillance system to monitor safety behaviors.  Establishing a fall reduction program in newborn centers insures quality and safety for the newborn population, demonstrates and documents providers’ safety practices, improves outcomes and assists organizations in complying with the JC’s National Patient Safety Goal, 09.02.01.