Patient Safety in the Neonatal Intensive Care Unit
Section snippets
Error detection in neonatal intensive care units
The types and frequencies of reported errors are a function of the method of detection. A commonly used method is to review charts and interview care providers. Using this methodology, Kaushal and coworkers [2] reported that medication errors were frequent in a NICU—91 per 100 admissions. Medication errors not only were more frequent, but they also were significantly more likely to be associated with the potential for harm (a potential adverse drug event [ADE]) than medication errors in
Creating and sustaining a culture of safety
The aviation industry often is cited as a model for aggressively and successfully addressing the problem of safety in air travel. As impressive as their record in reducing fatalities that are associated with air travel has been, they continue to set aggressive goals. The safety goal for 2007 is to reduce the aviation fatal accident rate by an additional 80%, compared with 1996 rates [16]. In addition to setting clear goals, other characteristics of the aviation safety strategy are applicable to
Joint Commission on Accreditation of Healthcare Organizations patient safety goals
At the time of this review, the JCAHO has nine National Patient Safety Goals for 2005 [28]. Most of the safety goals are directly applicable to the NICU.
Goal #1 is to improve the accuracy of patient identification. At least two patient identifiers are to be used for administering medications or blood products, drawing blood samples or other specimens, and any other treatments or procedures. An active final verification process should be done before any invasive procedure to confirm correct
Summary
A major shift is underway in understanding how to achieve the best and safest outcomes for our patients. Landmark publications from the Institute of Medicine have served to set a national agenda for change, and the challenge has been picked up by policy-setting organizations such as the JCAHO [43], [44]. Patient safety is a characteristics of a high-quality care environment and should be integrated into quality improvement programs. Trying to make care safer immediately brings one face to face
References (45)
- et al.
The safety checklist program: creating a culture of safety in intensive care units
Jt Comm J Qual Improv
(2002) Planning the acoustic environment of a neonatal intensive care unit
Clin Perinatol
(2004)Preventing nosocomial bloodstream infection in very low birth weight infants
Semin Neonatol
(2002)- et al.
Microsystems in health care: part 9. Developing small clinical units to attain peak performance
Jt Comm J Qual Saf
(2003) - et al.
NIC/Q 2000: establishing habits for improvement in neonatal intensive care units
Pediatrics
(2003) - et al.
Medication errors and adverse drug events in pediatric inpatients
JAMA
(2001) - et al.
Voluntary anonymous reporting of medical errors for neonatal intensive care
Pediatrics
(2004) - et al.
Use of incident reports by physicians and nurses to document medical errors in pediatric patients
Pediatrics
(2004) - Classen D.C., Pestotnik S.L., Evans R.S., et al. Description of a computerized adverse drug event monitor using a...
- et al.
Methodology and rationale for the measurement of harm with trigger tools
Qual Saf Health Care
(2003)
Adverse drug event trigger tool: a practical methodology for measuring medication related harm
Qual Saf Health Care
Random audits for patient safety in the NICU
Pediatr Res
The process audit: often ignored but never insignificant
Qual Prog
Vigilant watching over: mothers' actions to safeguard their premature babies in the newborn intensive care nursery
J Perinat Neonatal Nurs
Parents' perspectives on errors in neonatal intensive care
Pediatr Res
Speak up initiatives
National agenda for action: patients and families in patient safety; nothing about me, without me
Patient fact sheet: 20 tips to help prevent medical errors in children
Prevention of medication errors in the pediatric inpatient setting
Pediatrics
Safety strategic goal
The evolution of Crew Resource Management training in commercial aviation
Int J Aviat Psychol
Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project
Health Serv Res
Cited by (14)
Anonymous reporting of medical errors from The Egyptian Neonatal Safety Training Network
2020, Pediatrics and NeonatologyCitation Excerpt :NICU is a highly complex, stressful, technology-driven environment, which provides multidisciplinary care to critically ill newborns.1
What Nurses Can Do Right Now to Reduce Medication Errors in the Neonatal Intensive Care Unit
2008, Newborn and Infant Nursing ReviewsIatrogenic Disorders in Modern Neonatology: A Focus on Safety and Quality of Care
2008, Clinics in PerinatologyCitation Excerpt :The reporting system set up by the Vermont Oxford Network is an important first step and needs to be made permanent, and expanded to all NICUs nationwide. Other methods, such as chart reviews, can help to identify errors that escaped reporting through the voluntary and mandatory reporting systems [86]. Individual case reviews through the departmental morbidity and mortality conferences, hospital quality assurance committees, and hospital risk management should help identify problem areas, perform root cause analysis to identify system deficiencies, and help develop protocols to enhance patient safety.
Medication errors in neonatology: a review
2007, Archives de PediatriePrescription and transcription errors in a neonatal unit
2006, Anales de PediatriaFocusing on patient safety in the Neonatal Intensive Care Unit environment
2017, Journal of Pediatric and Neonatal Individualized Medicine
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AHRQ P20 HS 11583.