Patient Safety in the Context of Neonatal Intensive Care: Research and Educational Opportunities

Abstract

Case reports and observational studies continue to report adverse events from medical errors. However, despite considerable attention to patient safety in the popular media, this topic is not a regular component of medical education, and much research needs to be carried out to understand the causes, consequences, and prevention of healthcare-related adverse events during neonatal intensive care. To address the knowledge gaps and to formulate a research and educational agenda in neonatology, the Eunice Kennedy Shriver National Institute of Child Health and Human Development invited a panel of experts to a workshop in August 2010. Patient safety issues discussed were the reasons for errors, including systems design, working conditions, and worker fatigue; a need to develop a "culture" of patient safety; the role of electronic medical records, information technology, and simulators in reducing errors; error disclosure practices; medicolegal concerns; and educational needs. Specific neonatology-related topics discussed were errors during resuscitation, mechanical ventilation, and performance of invasive procedures; medication errors including those associated with milk feedings; diagnostic errors; and misidentification of patients. This article provides an executive summary of the workshop.

Use of Temporary Names for Newborns and Associated Risks

“…1,2 The Eunice Kennedy Shriver National Institute of Child Health and Human Development identified wrongpatient errors in NICUs as 1 of 5 domains of errors in neonatology that require further research. 3 Because there can be no delay in registering newborns and giving them identification wristbands, some hospitals assign newborns temporary first names, such as Babyboy or Babygirl. One theory why NICUs are prone to wrongpatient errors is the use of these nondistinct first names; however, no studies have provided direct evidence to support this hypothesis, nor have any demonstrated if transitioning to a naming convention that better distinguishes neonates from one another would prevent wrongpatient errors.…”

Prospective, controlled study of an intervention to reduce errors in neonatal antibiotic orders

“…These pilot data provide insight into the benefits of dosage calculation packages for neonatal medication orders, an area previously identified as a knowledge gap in NICU patient safety. 20 Although our intervention greatly reduced potential errors and omissions, these errors were not eliminated owing to practitioner behavior. For example, the ICOS-DS was designed for electronic transmission of the order to pharmacy.…”

Surgical resident education in patient safety: where can we improve?

“…To successfully address these concerns will require interventions involving individuals at all levels, from leadership to the most junior trainees that promote psychological safety within the team [25,26]. Furthermore, institutional leaders will need to emphasize with all personnel that safety is valued above production or efficiency [27]. Fortunately, improvements in one safety domain are likely to be synergistic with resultant improvements in the other domains [8,13].…”