OBJECTIVE. The fall of a newborn infant to the hospital floor is an error that has received little or no attention in medical publications. We sought to analyze the circumstances surrounding all such falls that occurred in an 18-hospital health care system during a 3-year period.
METHODS. Information was located by using electronic and risk-management records. Demographic features, circumstances of the fall, and outcomes were tabulated for each event.
RESULTS. During the study period, 88774 live births occurred at the Intermountain Healthcare hospitals. Fourteen neonatal in-hospital falls were identified during this period (incidence estimate: 1.6 falls per 10000 births). Seven falls occurred when a parent, holding the infant in a hospital bed or reclining chair, fell asleep and the infant fell to the floor. Six of these 7 falls occurred between 1:30 am and 9:00 am. Four falls occurred in the delivery room, 2 in the hallway while a nurse was wheeling a bassinette, and 1 from an infant swing. No deaths occurred. One patient sustained a depressed skull fracture and was transported to the regional children's hospital. At hospital discharge, 13 of the 14 were reported to have a normal examination. No specific protocols for preventing in-hospital falls of neonates were in place.
CONCLUSIONS. If the incidence of a neonatal in-hospital fall in this study is representative, then 600 to 700 such falls occur annually in the United States. Relatively few scenarios explain the majority of falls. We speculate that the prevalence of this error could be reduced significantly by enacting programs aimed at eliminating or monitoring the most common circumstances under which these falls occur.
Improving the safety of hospitalized patients is widely recognized as a critical health care industry need.1,2 Safety is a primary concern for all hospitalized patients, but it should be a particularly high priority for hospitalized children. Recent reports on medical errors in hospitalized children are disturbing,3,4 and they illustrate that effective strategies for preventing these errors are lacking.
Among elderly patients, falls in the hospital have been widely reported, and implementing tools for identifying these events and preventing such falls have been largely successful.5–8 In contrast, falls of neonates to the hospital floor, obviously an uncommon error compared with hospital falls of the elderly, has received little attention. Falls are the most common cause of accidental injury of neonates outside the hospital,9 but little has been published regarding in-hospital neonatal falls. We know of no estimates of the incidence of this problem; neither are we aware of any specific programs to prevent these falls. The lack of information on in-hospital falls of neonates leads us to conclude that this problem is understudied and that efforts to prevent these falls are inadequate.
As part of our commitment to improve patient safety, we sought information on every fall of a newborn infant in every Intermountain Healthcare hospital during a 3-year period. Intermountain Healthcare is a multihospital health care system in the western United States and includes 18 hospitals that offer obstetric services. The intent of this study was to discover and analyze the circumstances of each fall and subsequently to devise and implement new prevention strategies on the basis of this information.
Data were collected from archived Intermountain Healthcare records. The information collected was limited to the data and information displayed in tables and figures of this report. Data were obtained for patients who were born in any of the 18 Intermountain Healthcare hospitals that offer obstetric services, with a date of birth from January 1, 2004, through December 31, 2006. In-hospital falls were ascertained in 2 ways: (1) all cases filed with the Intermountain Healthcare Risk Management Department (paper records) were reviewed, and (2) International Classification of Diseases, Ninth Revision, codes were queried electronically by using electronic medical charts including discharge summaries, problem lists, and case mix (the billing, coding, and financial data mart used by Intermountain Healthcare).
The program used for data collection was a modified subsystem of “Clinical Workstation.” Clinical Workstation is a Web-based electronic medical chart application that stores demographic and clinical information, such as history, physical examination results, laboratory data, problem lists, and discharge summaries. The 3M Company (Minneapolis, MN) approved the structure and definitions of all data points for use within the program. Data were managed and accessed by authorized data analysts. The Intermountain Healthcare institutional review board approved the study.
During the 36-month period investigated, 14 infants were identified as having sustained a fall in the hospital. The Intermountain Healthcare hospitals delivered 88774 live births during this period. Thus, the incidence of a reported neonatal fall in this health care system was 1.6 falls per 10000 live births. One or more neonatal falls were identified to have occurred in 8 of the hospitals. The incidence within each hospital ranged from 0 in 10000 to 4.0 in 10000. Of the 14 falls, 12 were identified through electronic means, whereas 2 additional cases, not identified electronically, were found through risk-management records.
Demographic features of the 14 neonates who sustained an in-hospital fall are given in Table 1. Thirteen of the 14 were delivered at or near term. Their falls generally occurred on the first day after birth. The patient who was delivered preterm (patient 6) fell from a swing in a neonatal intensive care stepdown unit 78 days after birth.
Circumstances surrounding the 14 falls are shown in Table 2. A common situation involved a mother holding the infant in her arms while lying in her hospital bed; the mother fell asleep and the infant subsequently fell to the floor. Two of the 4 mothers who dropped their infant in this manner had received a sedative medication within 6 hours before the fall. These falls generally occurred in the early morning hours (3:00, 5:00, 9:00, and 12:45). Three falls occurred when the father was holding the infant in a reclining chair or bed; the father fell asleep and the infant subsequently fell to the floor. These falls all occurred in the early morning hours (1:30, 3:45, and 6:45). Most of the falls were of an estimated distance of 32 to 43 inches and onto a linoleum-covered concrete floor.
Outcomes of the neonates who sustained a fall are shown in Table 3. All 14 patients lived. One patient (patient 10) had a depressed skull fracture seen on skull radiographs and was transferred to the regional children's hospital, where she did not undergo a neurosurgical procedure, and was discharged after 2 days with no apparent problems. Only 1 patient (patient 5) had an axial head computed tomography scan (without contrast). This showed mild soft tissue swelling over the vertex bilaterally, the possibility of a small subgaleal hematoma, and no fracture and no mass effect or shift. One patient (patient 3) had an abnormal examination at the time of hospital discharge, with a large bruise on the forehead.
No protocol for evaluating neonates after a hospital fall and no protocol specifically aimed at preventing in-hospital falls of neonates were in place in any of the hospitals; however, mothers were to have received general education about infant safety and security at the time they were admitted to the obstetric floor. Also, mothers were to have received the offer to have their neonate cared for in the nursery if she was tired; otherwise, rooming-in was encouraged.
In-hospital falls of toddlers is a widely recognized problem. Helfer et al10 described 85 such falls of children who were younger than 5 years, and Lyon and Oats11 reported 207 falls of children who were younger than 6 years. These were predominantly the result of hospitalized toddlers' climbing over bedrails. Certainly, out-of-hospital falls are recognized as the most common cause of accidental injury among neonates.9,12 Despite substantial efforts to prevent in-hospital falls of toddlers and to prevent out-of-hospital falls among neonates, the problem of in-hospital falls of neonates is not a widely recognized problem.
The most common situation that we found to explain an in-hospital fall was from the arms of a parent who fell asleep holding the infant (cases 1, 2, 3, 4, 8, 11, and 13). In 6 of 7 instances, the fall occurred in the early morning hours, and it occurred shortly after noon in the seventh. Byard13 reported that nighttime breastfeeding in bed was a cause of neonatal mortality. Surveying death records in Southern Australia in 1996, he identified 3 of 28 cases of unexpected infant death in which accidental asphyxia was associated with breastfeeding while cosleeping, but he reported no cases of deaths from a fall from a sleeping breastfeeding mother. Perhaps 1 way to reduce this variety of fall would be specifically to inform parents about this type of fall and to implement policies to prevent cosleeping in the hospital.14 We are now asking our nurses to perform a visual check every 30 minute on any infant who is known to be in the arms of a parent in a bed or a recliner between the hours of 12:00 am and 9:00 am. Because half of the mothers who dropped their infants were under sedation, specific efforts are needed to avoid the situation of having an unobserved, sedated mother breastfeed her neonate while in bed.
Another common situation (cases 9 and 12) involved pushing a bassinette with wheels and encountering an uneven floor between the elevator floor and the exiting floor. The cart used in our system is a metal frame into which is set a plastic bassinette. The bassinette does not lock into place. If the nurse pushing this type of cart holds onto the metal, not onto the plastic bassinette, then this type of fall should not occur. On that basis, we are instructing our nurses who have occasion to wheel a neonate in a bassinette to hold onto and push the metal portion of the cart. Redesigning the bassinette cart, by providing a locking mechanism between the frame and the bassinette, and redesigning the recliner both would be welcome advances. It may be more effective to design hazards out of the environment than to attempt to change personal behavior.
Four falls occurred in the delivery room. Two involved delivery before the mother was positioned on the delivery table, and 2 slipped through the hands of the delivering physician. One approach to reducing these events, taken by the Johns Hopkins Hospital, is the use of a specific perinatal patient safety nurse.15 The primary responsibility of this nurse is to promote safe care for mothers and infants by keeping patient safety as a focus of all unit operations and clinical practices.
We found no guidelines in our system for evaluating a neonate after an in-hospital fall. The evaluations of our 14 patients varied considerably, from obtaining a head computed tomography scan to no mention of the fall in the medical chart. Duhaime et al16 reviewed the evaluation of 100 children who were 11 days to 24 months old and sustained an out-of-hospital fall. They reported that when the fall was from a distance of >4 ft, a linear skull fracture was more likely. Indeed, injury from a fall has been correlated with the distance fallen; the nature of the contact surface; and the body mass, age, and ability of the victim to dissipate the impact force.17–19 Because most falls that we found involved a distance of ∼3 ft and to a hard surface, we speculate that guidelines for evaluation would be appropriate and that, at a minimum, skull radiographs, a physical examination, and 24 hours of in-hospital monitoring should be performed.
In-hospital falls of neonates must be viewed as preventable. Whether our new efforts toward accomplishing this goal are successful can be assessed only in the coming years. To assist hospitals eliminate this error, we invite the suggestions of others regarding their prevention strategies. Also, to improve consistency of care, we invite suggestions regarding guidelines that others have implemented for evaluating neonates who have sustained in-hospital falls.
- Accepted April 14, 2008.
- Address correspondence to Robert D. Christensen, MD, Intermountain Healthcare, 4303 Harrison Blvd, Ogden, UT 84403. E-mail:
The authors have indicated they have no financial relationships relevant to this article to disclose.
What's Known on This Subject
Falls are the most common cause of accidental injury of neonates outside the hospital, but little has been published regarding falls of neonates to the hospital floor.
What This Study Adds
We used the electronic chart repositories and risk-management files to find each in-hospital fall of a neonate in the Intermountain Healthcare system during a 3-year period. Fourteen falls occurred. The circumstances surrounding each fall and the outcomes were tabulated.
- ↵Dyer O. Simple precautionary measures can reduce numbers of falls in hospital. BMJ. 2007;334 (7591):447
- ↵Agran PF, Anderson C, Winn D, Trent R, Walton-Haynes L, Thayer S. Rates of pediatric injuries by 3-month intervals for children 0 to 3 years of age. Pediatrics. 2003;111 (6). Available at: www.pediatrics.org/cgi/content/full/111/6/e683
- ↵Helfer RE, Slovis TL, Black M. Injuries resulting when small children fall out of bed. Pediatrics. 1977;60 (4):533– 535
- ↵Lyons TJ, Oates RK. Falling out of bed: a relatively benign occurrence. Pediatrics. 1993;92 (1):125– 127
- ↵Warrington SA, Wright CM, ALSPAC Study team. Accidents and resulting injuries in premobile infants: data from the ALSPAC study. Arch Dis Child. 2001;85 (2):104– 107
- ↵Thompson DG. Safe sleep practices for hospitalized infants. Pediatr Nurs. 2005;31(5) :403– 409
- ↵Duhaime AC, Alario AJ, Lewander WJ, et al. Head injury in very young children: mechanisms, injury types, and opthalmologic findings in 100 hospitalized patients younger than 2 years of age. Pediatrics. 1992;90 (2):179– 185
- Copyright © 2008 by the American Academy of Pediatrics