A critical incident is described as any sudden unexpected event that has the power to overwhelm the usual effective coping skills of an individual or a group and can cause significant psychological distress in usually healthy persons. A Just Culture model to deal with critical incidents is an approach that seeks to identify and balance system events and personal accountability. This article reports a critical incident that occurred at the Neonatal Intensive Care Unit, Methodist Hospital of Indianapolis, when 5 infants received an overdose of heparin that resulted in the death of 3 infants. Although care of the family after the critical incident was the immediate priority, the focus of this article was on the recovery and reintegration of the NICU staff after a critical incident based on the Just Culture philosophy.

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Child Health and Pathology, Hanover, New Hampshire. I n t r a c r a n i a l hemorrhage i n premature human neonates i s a major c a u s e of m o r t a l i t y and m o r b i d i t y . The hemorrhage u s u a l l y o r i g in a t e s i n t h e GM o v e r the c a u d a t e n u c l e u s . Although s t r u c t u r a l s u s c e p t i b i l i t y o f the GM blood v e s s e l s t o neonatal s t r e s s has been s u g g e s t e d a s a c a u s e f o r hemorrhage, h i s t o l o g i c a l confirmat i o n i s l a c k i n g . Because c o r t i c a l hemorrhage i n prematures i s l e s s f r e q u e n t , we compared the u l t r a s t r u c t u r a l morphology of blood v e s s e l s i n the GM w i t h t h o s e o f t h e c e r e b r a l c o r t e x . W e s t u d i e d prematures o f 22-27 weeks g e s t a t i o n with and w i t h o u t GM and i n t r a v e n t r i c u l a r hemorrhage. Autopsy m a t e r i a l s were obtained l e s s t h a n 2 hours postmortem, f i x e d i n g l u t a r a l d e h y d e and examined by t r a n s m i s s i o n e l e c t r o n microscopy. Our o b s e r v a t i o n s a r e t h a t t h e c o r t i c a l blood v e s s e l s uniformlyhave mature c h a r a c t e r i s t i c s : continuous basal lamina, t i g h t junct i o n s , absence o f f e n e s t r a t i o n s and c m p l e t e p e r i c y t i c e n c i r c l ement. I n t h e GM, however, t h e r e were 2 t y p e s of blood v e s s e l s . One t y p e resembled the c o r t i c a l v e s s e l s w i t h a l l t h e c h a r a c t e r i st i c s o f m a t u r i t y . The second t y p e had a l l t h e c h a r a c t e r i s t i c s of immature blood v e s s e l s : p r e s e n c e o f f e n e s t r a t i o n s and absence of a c o n t i n u o u s basal lamina, t i g h t j u n c t i o n s , and f u l l e n c i r c l e m e n t by p e r i c y t e s .p o s t u l a t e t h a t t h e p r e s e n c e o f s t r u c t u r a l l y i m n a t u r e b l o o d v e s s e l s i n the GM makes this a r e a more s u s c e p t i b l e t o hemorrhage. U n i v e r s i t v METABOLIC EFFECTS OF GLUCOSE ADMINISTRATION I N THEASPHYXIATED NEWBORN RAT. Paul F. Ploegman, Robert D. J a n s e n (Spon. by Richard L. S c h r e i n e r ) . I n d i a n a School of Medicine. I n d i a n a U n i v e r s i t v H o s~i t a l s . > .Department of P e d i a t r i c s , I n d i a n a p o l i s . B r a i n i n j u r y r e s u l t i n g from b i r t h asphyxia h a s been c o r r el a t e d w i t h e l e v a t e d CNS l a c t a t e l e v e l s . T h i s s t u d y i n v e s t i g a t e 0 t h e m e t a b o l i c r e s p o n s e o f newborn r a t pups t o a g l u c o s e b o l u s g i v e n d u r i n g normoxic recovery from asphyxia a t b i r t h . Three groups were s t u d i e d : Group A-G, a s p h y x i a t e d i n 5% 02 f i r s t 20 min o f l i f e , g i v e n g l u c o s e 1 g/kg a t 20 min; Group A-S asphyxia t e d a s group A-G b u t g i v e n s a l i n e a t 20 min; Group C-G kept i n room a i r from b i r t h , g i v e n g l u c o s e a t 20 min. Blood and b r a i n t i s s u e were o ...

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