Newborn Falls in Pennsylvania: An Analysis of Recent Events and a Review of Prevention Strategies


  • Elizabeth Kukielka Patient Safety Authority
  • Susan C. Wallace Patient Safety Authority



newborn fall, newborn drop, infant fall, maternal fatigue, breastfeeding, fall prevention


Despite increasing recognition of the potential risks associated with in-hospital newborn falls among health professionals, new parents are frequently unaware of the possibility of dropping their newborn, especially in the hospital. Although most newborn falls do not result in lasting harm to the newborn, they may necessitate additional healthcare services and cause stress to all involved parties. An analysis of reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) from January 2014 through December 2018 identified 318 events specifically related to newborn falls in the hospital following birth. An increase in the number and rate of serious newborn fall events reported to PA-PSRS was observed compared with a previous analysis by Wallace. Newborn falls were most commonly associated with a caregiver falling asleep (168 events, or 52.8%) and with newborn feeding (72 events, or 22.6%). Strategies to prevent newborn falls in the hospital include focusing efforts on providing support for exhausted parents during the critical time following the birth, offering periods of rest for new parents whenever they are tired, increasing the frequency of rounding when new mothers are breastfeeding, and promoting a midday break in visiting hours.

Author Biographies

Elizabeth Kukielka, Patient Safety Authority

Elizabeth Kukielka ( is a patient safety analyst on the Data Science and Research team at the Patient Safety Authority. Before joining the PSA, she was a promotional medical writer for numerous publications, including Pharmacy Times and The American Journal of Managed Care. Kukielka also worked for a decade as a community pharmacist and pharmacy manager, with expertise in immunization delivery, diabetes management, medication therapy management, and pharmacy compounding.

Susan C. Wallace, Patient Safety Authority

Susan C. Wallace is a senior patient safety liaison with the Patient Safety Authority for the South Central region of Pennsylvania, as well as a Core Team Lead for the PSA’s Center of Excellence for Improving Diagnosis. Prior to her current role, Wallace worked as a director of risk management, patient safety officer, and safety analyst.


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Newborn baby on mothers shoulder.



How to Cite

Kukielka, E., & Wallace, S. C. . (2019). Newborn Falls in Pennsylvania: An Analysis of Recent Events and a Review of Prevention Strategies. Patient Safety, 1(2), 45–53.



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