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.

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