An Initiative to Prevent Newborn Drops through the Implementation of a Prevention Bundle at a Children's Hospital

Newborn drops are a problem in hospitals across the United States. This type of fall, characterized by an infant slipping from the arms or lap of a parent or caregiver, can have severe consequences and result in emotional distress for families. The lack of a comprehensive approach to preventing newborn drops at our children's hospital highlighted an urgent need for action. Although existing research has focused on maternal-child acute care units, a notable gap remains in evidence-based solutions for children's hospitals. We developed a baby drop prevention bundle to address this problem.

We used improvement science to implement and evaluate the bundle across the hospital. A Plan-Do-Study-Act model guided iterative cycles of improvement. The bundle included staff and caregiver education, frequent intentional safety rounding for newborns aged 30 days or younger, an infant fall risk assessment, a supportive pillow for newborn holding and feeding, protected maternal rest periods, and standardized reporting and debriefing of infant drops and near misses. The primary outcome measure was the incidence of newborn drops; the process measure was compliance with the bundle, and an additional measure was near-miss events.

Since implementing the baby drop prevention bundle, there have been 0 incidents of newborn drops. We have observed 10 near-miss events since May 2025. Compliance reached 100% with the rounding plan and 90% with the use of the supportive pillow during 10 months.

A baby drop prevention bundle likely reduced the risk of newborn drops and promoted a culture of safe sleep at a children's hospital.