Peer-reviewed article
An Initiative to Prevent Newborn Drops through the Implementation of a Prevention Bundle at a Children's Hospital.
Birkinshaw HM, Owens AR, Gilchrist AC, Barrows J, Lusk J ·
Summary
Written by AI, not yet AICS's view · claude-haiku-4-5-20251001This study describes the implementation of a baby drop prevention bundle at a children's hospital in the United States to address the problem of infants slipping from caregivers' arms or laps. The bundle included staff and caregiver education, safety rounding, fall risk assessment, supportive pillows, protected rest periods for mothers, and standardized reporting of incidents. After 10 months of implementation, there were zero recorded newborn drops, though 10 near-miss events were observed, and the hospital achieved high compliance with the bundle components.
Key points
- Newborn drops can result in severe consequences and emotional distress for families
- The bundle included six components: education, frequent safety rounding, fall risk assessment, supportive pillow, protected rest periods, and standardized reporting
- Zero incidents of newborn drops occurred over the 10-month implementation period
- Compliance reached 100% with the rounding plan and 90% with the supportive pillow use
- Ten near-miss events were detected and reported during the study period
Limitations
This is a single-site quality improvement initiative without a comparison group, so it cannot determine whether outcomes were due to the bundle or other factors. The short 10-month timeframe and zero incident outcome limit the ability to draw generalizable conclusions about the bundle's effectiveness.
Abstract
Introduction 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. Methods 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. Results 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. Conclusions A baby drop prevention bundle likely reduced the risk of newborn drops and promoted a culture of safe sleep at a children's hospital.