Patient safety in the NICU: a comprehensive review

Intravenous Medication Administration Safety with Smart Infusion Pumps in the Neonatal Intensive Care Unit: An Observational Study

INTRODUCTION

Infants in the neonatal intensive care unit (NICU) are among the most vulnerable patient populations and medication errors are a significant source of risk and harm to neonates. Smart infusion pumps have been implemented to support the safe medication administration process; however, the effect of using smart infusion pumps on medication safety in the NICU is still unclear.

METHODS

We conducted an observational study with a prospective point-prevalence approach to investigate intravenous (IV) medication administration errors in the NICU at one academic medical center in the USA. Observations were conducted in 48 days in a 3-month data collection period in 2019.

RESULTS

We observed a total of 441 patients with 905 IV medication administrations during the data collection period. The total number of errors was 130 (14.4 per 100 administrations). Of these, the most frequent errors were selecting the wrong drug library entry (5.3 per 100 administrations), unauthorized medication (0.7 per 100 administrations), and wrong dose (0.6 per 100 administrations). Sixty-eight errors (7.5 per 100 administrations) were unlikely to cause harm despite reaching the patient (category C errors), while the rest did not reach the patient.

CONCLUSION

We identified the medication errors, which was unique to NICU populations, but no harm to the patients were identified. Most errors occurred due to a lack of compliance of using smart pump technology; therefore, potential exists to maximize safety related to medication administration practices in the NICU through hospital policy change and increasing adherence to appropriate use of smart pump technology.

Implementing a Robust Process Improvement Program in the Neonatal Intensive Care Unit to Reduce Harm

INTRODUCTION

Preventable harm continues to occur with critically ill neonates despite efforts by hospital neonatal intensive care units (NICUs) to improve processes and reduce harm. Attaining significant and sustainable improvements will require training including leadership support, mentoring, and patient family engagement to improve care processes. This paper describes the implementation of a robust process improvement (RPI) program in the NICU to reduce harm.

METHODS

Leaders, staff, and parents were trained in RPI concepts and tools. Multidisciplinary teams including parent members applied the training and received regular mentorship for their improvement initiatives.

RESULTS

Participants (N = 67) completed pretraining and post-training surveys. Training scores (0-10 scale) improved from an average of 4.45-7.60 (p < .001) for confidence in leading process improvement work, 2.36 to 7.49 (p < .001) for RPI knowledge, and 2.19 to 7.30 (p < .001) for confidence in using RPI tools; relative improvement of 71%, 217%, and 233% respectively. Participants applied their RPI training on improvement initiatives that resulted in improvements of central line blood stream infections, very low birth weight infant nutrition, and unplanned extubations.

CONCLUSIONS

Implementing an RPI program in the NICU to reduce harm resulted in significant and sustainable improvements on their improvement initiatives.

Defining the Epidemiology of Safety Risks in Neonatal Intensive Care Unit Patients Requiring Surgery

OBJECTIVE

The aim of the study was to determine the incidence, type, severity, preventability, and contributing factors of nonroutine events (NREs)-events perceived by care providers or skilled observers as a deviations from optimal care based on the clinical situation-in the perioperative (i.e., preoperative, operative, and postoperative) care of surgical neonates in the neonatal intensive care unit and operating room.

METHODS

A prospective observational study of noncardiac surgical neonates, who received preoperative and postoperative neonatal intensive care unit care, was conducted at an urban academic children's hospital between November 1, 2016, and March 31, 2018. One hundred twenty-nine surgical cases in 109 neonates were observed. The incidence and description of NREs were collected via structured researcher-administered survey tool of involved clinicians. Primary measurements included clinicians' ratings of NRE severity and contributory factors and trained research assistants' ratings of preventability.

RESULTS

One or more NREs were reported in 101 (78%) of 129 observed cases for 247 total NREs. Clinicians reported 2 (2) (median, interquartile range) NREs per NRE case with a maximum severity of 3 (1) (possible range = 1-5). Trained research assistants rated 47% of NREs as preventable and 11% as severe and preventable. The relative risks for National Surgical Quality Improvement Program - pediatric major morbidity and 30-day mortality were 1.17 (95% confidence interval = 0.92-1.48) and 1.04 (95% confidence interval = 1.00-1.08) in NRE cases versus non-NRE cases.

CONCLUSIONS

The incidence of NREs in neonatal perioperative care at an academic children's hospital was high and of variable severity with a myriad of contributory factors.

Associations between safety perceptions and medical error reporting among neonatal intensive care unit staff

INTRODUCTION

Critically ill neonates are particularly susceptible to medical errors; however, few studies have evaluated NICU safety climate in the context of medical error reporting. This study aims to identify the association between perceptions of safety and culture among NICU staff with medical error reporting behaviours.

METHODS

This study used a convenience sample of 79 NICU staff members (38 Nurses and 41 Respiratory Therapists). Questionnaires consisted of demographic factors (years of experience, sex and education), the Safety Attitudes Questionnaire (SAQ) and hypothetical medical error reporting scenarios (categorized into minor harm or major harm). The SAQ consists of six domains: job satisfaction, teamwork climate, safety climate, perceptions of management, working conditions and stress recognition. Scores ranged from 0-5, with a 5 indicating a more positive perception. Logistic regression was used to determine statistically significant predictors for each individual harm scenario (odds of being very likely/likely to report vs. all other responses).

RESULTS

Among those who completed the study, approximately 84.8% were female. Safety attitude domain scores were similar for both NICU respiratory therapists and nurses across all domains except for job satisfaction and stress. Respiratory therapists reported higher levels of job satisfaction compared to nurses (24 vs. 23, respectively, p = 0.01). However, nurses reported higher levels of stress management compared to respiratory therapists (12 vs. 9, respectively, p < 0.01). While we did not find a significant association between safety attitudes and hypothetical medical error reporting, NICU staff overall were more likely to report major medical errors compared to minor medical errors.

CONCLUSIONS

This study suggests that safety climate may not play a significant role in promoting medical error reporting in the NICU setting.

RELEVANCE TO CLINICAL PRACTICE

Interventions aimed at increasing medical error reporting should also incorporate established employees rather than targeting new employees only.

A First-line management team's strategies for sustaining resilience in a specialised intensive care unit-a qualitative observational study

OBJECTIVES

Acute care units manage high risk patients at the edge of scientifically established treatments and organisational constraints while aiming to balance reliability to standards with the needs of situational adaptation (resilience). First-line managers are central in coordinating clinical care. Any systemic brittleness will be evident only in retrospect through, for example, care quality measures and accident statistics. This challenges us to understand what successful managerial strategies for adaptation are and how they could be improved. The managerial work of balancing reliability and adaptation is only partially understood. This study aims to explore and describe how system resilience is enhanced by naturally occurring coordination performed in situ by a management team under variable circumstances.

DESIGN

An explorative observational study of a tertiary neonatal intensive care unit (NICU) in Sweden. One year of broad preparatory work followed by focused shadowing observations of coordination analysed through inductive-deductive content analysis from a perspective of resilience engineering.

PARTICIPANTS

A team of managers (ie, clinical coordinators, head nurses, senior medical doctors).

RESULTS

The results describe a functional relationship between operational stress and a progression of adjustments in the actual situation, expressed through recurring patterns of adaptation. Managers focused on maintaining coherence in escalating problematic situations by facilitating teamwork through goalsetting, problem-solving and circumventing the technical systems' limitations.

CONCLUSIONS

Coordination supports a coherent goal setting by increased team collaboration and is supported by team members' abilities to predict the behaviour of each other. Our findings suggest that in design of future research or training for coordination, the focus of assessment and reflection on adaptive managerial responses may lie on situations where the system was 'stretched' or 'needed reorganisation' and that learning should be about whether the actions were able to achieve short-term goals while preserving the long-term goals.

Perspectives and practices of healthcare providers and caregivers on healthcare-associated infections in the neonatal intensive care units of two hospitals in Ghana

Healthcare-associated infections (HAIs) remain a serious threat to patient safety worldwide, particularly in low- and middle-income countries. Reducing the burden of HAIs through the observation and enforcement of infection prevention and control (IPC) practices remains a priority. Despite growing emphasis on HAI prevention in low- and middle-income countries, limited evidence is available to improve IPC practices to reduce HAIs. This study examined the perspectives of healthcare providers (HPs) and mothers in the neonatal intensive care unit on HAIs and determined the major barriers and facilitators to promoting standard IPC practices. This study draws on data from an ethnographic study using 38 in-depth interviews, four focus group discussions and participant observation conducted among HPs and mothers in neonatal intensive care units of a secondary- and tertiary-level hospital in Ghana. The qualitative data were analysed using a grounded theory approach, and NVivo 12 to facilitate coding. HPs and mothers demonstrated a modest level of understanding about HAIs. Personal, interpersonal, community, organizational and policy-level factors interacted in complex ways to influence IPC practices. HPs sometimes considered HAI concerns to be secondary in the face of a heavy clinical workload, a lack of structured systems and the quest to protect professional authority. The positive attitudes of some HPs, and peer interactions promoted standard IPC practices. Mothers expressed interest in participation in IPC activities. It however requires systematic efforts by HPs to partner with mothers in IPC. Training and capacity building of HPs, provision of adequate resources and improving communication between HPs and mothers were recommended to improve standard IPC practices. We conclude that there is a need for institutionalizing IPC policies and strengthening strategies that acknowledge and value mothers' roles as caregivers and partners in IPC. To ensure this, HPs should be better equipped to prioritize communication and collaboration with mothers to reduce the burden of HAIs.

Robotic Therapy: Cost, Accuracy, and Times. New Challenges in the Neonatal Intensive Care Unit

Background: The medication process in the Neonatal Intensive Care Unit (NICU), can be challenging in terms of costs, time, and the risk of errors. Newborns, especially if born preterm, are more vulnerable to medication errors than adults. Recently, robotic medication compounding has reportedly improved the safety and efficiency of the therapeutic process. In this study, we analyze the advantages of using the I.V. Station^® system in our NICU, compared to the manual preparation of injectable drugs in terms of accuracy, cost, and time. Method: An in vitro experimental controlled study was conducted to analyze 10 injectable powdered or liquid drugs. Accuracy was calculated within a 5% difference of the bottle weight during different stages of preparation (reconstitution, dilution, and final product). The overall cost of manual and automated preparations were calculated and compared. Descriptive statistics for each step of the process are presented as mean ± standard deviation or median (range). Results: The median error observed during reconstitution, dilution, and final therapy of the drugs prepared by the I.V. Station^® ranged within ±5% accuracy, with narrower ranges of error compared to those prepared manually. With increasing preparations, the I.V. Station^® consumed less materials, reduced costs, decreased preparation time, and optimized the medication process, unlike the manual method. In the 10 drugs analyzed, the time saved from using the I.V. Station^® ranged from 16 s for acyclovir to 2 h 57 min for teicoplanin, and cost savings varied from 8% for ampicillin to 66% for teicoplanin. These advantages are also capable of continually improving as the total amount of final product increases. Conclusions: The I.V. Station^® improved the therapeutic process in our NICU. The benefits included increased precision in drug preparation, improved safety, lowered cost, and saved time. These advantages are particularly important in areas such as the NICU, where the I.V. Station^® could improve the delivery of the high complexity of care and a large amount of intravenous therapy typically required. In addition, these benefits may lead to the reduction in medication errors and improve patient and family care; however, additional studies will be required to confirm this hypothesis.

An Ethnography of Parents' Perceptions of Patient Safety in the Neonatal Intensive Care Unit

BACKGROUND

Parents of neonates are integral components of patient safety in the neonatal intensive care unit (NICU), yet their views are often not considered. By understanding how parents perceive patient safety in the NICU, clinicians can identify appropriate parent-centered strategies to involve them in promoting safe care for their infants.

PURPOSE

To determine how parents of neonates conceptualize patient safety in the NICU.

METHODS

We conducted qualitative interviews with 22 English-speaking parents of neonates from the NICU and observations of various parent interactions within the NICU over several months. Data were analyzed using thematic content analysis. Findings were critically reviewed through peer debriefing.

FINDINGS

Parents perceived safe care through their observations of clinicians being present, intentional, and respectful when adhering to safety practices, interacting with their infant, and communicating with parents in the NICU. They described partnering with clinicians to promote safe care for their infants and factors impacting that partnership. We cultivated a conceptual model highlighting how parent-clinician partnerships can be a core element to promoting NICU patient safety.

IMPLICATIONS FOR PRACTICE

Parents' observations of clinician behavior affect their perceptions of safe care for their infants. Assessing what parents observe can be essential to building a partnership of trust between clinicians and parents and promoting safer care in the NICU.

IMPLICATIONS FOR RESEARCH

Uncertainty remains about how to measure parent perceptions of safe care, the level at which the clinician-parent partnership affects patient safety, and whether parents' presence and involvement with their infants in the NICU improve patient safety.

SEGURANÇA DA TERAPIA MEDICAMENTOSA EM NEONATOLOGIA: OLHAR DA ENFERMAGEM NA PERSPECTIVA DO PENSAMENTO ECOLÓGICO RESTAURATIVO

RESUMO Objetivo: analisar os fatores que interferem na segurança no processo de medicação em uma unidade de terapia intensiva (UTI) neonatal. Método: estudo exploratório com abordagem qualitativa. A coleta ocorreu no período de dezembro de 2014 a março de 2015, através de grupos focais e caminhada fotográfica, na perspectiva do pensamento ecológico restaurativo, com 12 profissionais de enfermagem da UTI neonatal de um hospital público da Região Sul do Brasil. As informações foram organizadas através do software Nvivo 10 e submetidas à análise de conteúdo temática. Resultados: a partir da análise, emergiram as seguintes categorias temáticas: Abordagem individualizada e cultura de punição dos erros de medicação; Fatores de (in)segurança relacionados à estrutura física dos medicamentos na UTI neonatal; Fatores de (in)segurança relacionados a rotinas e protocolos; e A enfermagem como barreira para a ocorrência de falhas de prescrição médica. Conclusão: o estudo demonstra a complexidade do processo de medicação em neonatologia e destaca pontos críticos no mesmo que podem ocasionar falhas e eventos adversos, assim como propostas de melhoria para prevenir os erros. Destaca-se o papel da equipe de enfermagem na detecção de erros da prescrição medicamentosa, funcionando como última barreira para prevenção e redução de erros associados à medicação.

Patient safety culture perceptions in the college of dentistry

A positive safety culture is essential to patient safety because it improves quality of care. The aim of this study was to assess staff and student perceptions of the patient safety culture in the clinics of the College of Dentistry at King Saud University in Saudi Arabia.A cross-sectional study was conducted in the College of Dentistry at King Saud University in Saudi Arabia. It included 4th and 5th year students, interns, general practitioners, and dental assistants. The data were collected by using paper-based questionnaire of modified version of the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture. Data were entered into SPSS Version 20. Score on a particular safety culture dimension was calculated.The overall response rate was 72.8% (390/536). Team work dimension had the highest average percent positive dimension score (72.3%) while staffing had the lowest score (10%). Dental assistant had high agreement in Teamwork dimension (87.8%); Supervisor/Manager Expectations and Actions Promoting Patient Safety dimension (66.9%); Organizational Learning-Continuous Improvement dimension (79.1%); Management Support for Patient Safety dimension (84.5%); Feedback and Communication About Error dimension (58.3%); Frequency of Events Reported dimension (54.0%); Teamwork Across Units dimension (73.2%). Most of areas perceived that there is no event reported (76.1-85.3%) in the past 12 months.Overall patient safety grade is more than moderate in the clinic. Teamwork within Units and Organizational Learning-Continuous Improvement dimension had the highest score while staffing had the lowest score. Dental assistants perceived positive score in most dimensions while students perceived slight negative score in most dimensions.

Interventions to reduce medication errors in neonatal care: a systematic review

Background

Medication errors represent a significant but often preventable cause of morbidity and mortality in neonates. The objective of this systematic review was to determine the effectiveness of interventions to reduce neonatal medication errors.

Methods

A systematic review was undertaken of all comparative and noncomparative studies published in any language, identified from searches of PubMed and EMBASE and reference-list checking. Eligible studies were those investigating the impact of any medication safety interventions aimed at reducing medication errors in neonates in the hospital setting.

Results

A total of 102 studies were identified that met the inclusion criteria, including 86 comparative and 16 noncomparative studies. Medication safety interventions were classified into six themes: technology (n = 38; e.g. electronic prescribing), organizational (n = 16; e.g. guidelines, policies, and procedures), personnel (n = 13; e.g. staff education), pharmacy (n = 9; e.g. clinical pharmacy service), hazard and risk analysis (n = 8; e.g. error detection tools), and multifactorial (n = 18; e.g. any combination of previous interventions). Significant variability was evident across all included studies, with differences in intervention strategies, trial methods, types of medication errors evaluated, and how medication errors were identified and evaluated. Most studies demonstrated an appreciable risk of bias. The vast majority of studies (>90%) demonstrated a reduction in medication errors. A similar median reduction of 50-70% in medication errors was evident across studies included within each of the identified themes, but findings varied considerably from a 16% increase in medication errors to a 100% reduction in medication errors.

Conclusion

While neonatal medication errors can be reduced through multiple interventions aimed at improving the medication use process, no single intervention appeared clearly superior. Further research is required to evaluate the relative cost-effectiveness of the various medication safety interventions to facilitate decisions regarding uptake and implementation into clinical practice.

Preventing Pressure Injuries in Neonates Undergoing Therapeutic Hypothermia for Hypoxic-Ischemic Encephalopathy: An Interprofessional Quality Improvement Project

BACKGROUND

Hospital-acquired pressure injuries (HAPIs) can be caused by multiple factors including pressure, shear, friction, moisture/incontinence, device-related pressure, immobility, inactivity, and nutritional deficits. Along with immobility, medical device-related (MDR) HAPIs are a primary cause of pressure injury in neonates, as the clinical practice setting has become increasingly technologically advanced. It is estimated that up to 50% of HAPIs are MDR in pediatric patients. Neonates are at particular risk for HAPI because of their specific anatomical, physiological, and developmental vulnerabilities. A specific example of confluent factors that may increase risk for HAPI is the application of therapeutic hypothermia (TH) and continuous electroencephalography monitoring for neonates with hypoxic-ischemic encephalopathy (HIE).

INTERVENTIONS

An interprofessional team collaborated to expand upon existing evidence-based standards of care to address the needs of this specific population within the neonatal intensive care unit (NICU). Interventions centered on revision of current protocols, with efforts to optimize product selection, hardwire assessment practices, and refine documentation of patient care and outcomes.

METHODS

The team primarily utilized plan-do-study-act (PDSA) cycles to test and refine specific methods and strategies to reduce HAPIs. Tested solutions were adopted, adapted, or abandoned.

RESULTS

A sustained zero HAPI rate in the HIE population resulted. The team continues to collect, report, and utilize near-miss data to continue to refine the process as new risks are identified.

IMPLICATIONS FOR PRACTICE

Recognizing the unique skin protection needs of special populations within the NICU, such as those undergoing TH, is crucial. When evidence-based standards of care fail to adequately meet such needs, a collaborative approach to identifying, testing, and implementing population-specific solutions is essential.

IMPLICATIONS FOR RESEARCH

A paucity of literature regarding the unique skin protection needs for babies undergoing TH exists. Work should be done to better describe the influence of TH on skin integrity, with the goal of identifying population-specific protective measures.

Promoting teamwork may improve infant care processes during delivery room management: Florida perinatal quality collaborative's approach

BACKGROUND

LOCAL PROBLEM: Inadequate understanding of compliance with standardized evidence-based DR management.

INTERVENTIONS

Promote inter-professional teamwork and a bundle of interventions focusing on resuscitation team roles, equipment check, and debriefing using QI methodology. Optimize delivery room (DR) management to achieve 10-min SPO₂ targets, delayed-cord clamping (DCC), team role assignment and debriefings in >50% of deliveries, and achieve normothermia in >75% of infants.

METHODS

Over 15 months (Epoch 1 to 5), nine Florida hospitals implemented a DR management plan for infants <31 weeks gestational age or <1500 g (N=814) using quality improvement methodology.

RESULTS

There was increased compliance of DCC (36 to 66%), role assignment (53 to 98%), debriefing rates (33 to 76%) and having all seven pre-delivery preparedness components fulfilled (34 to 75%). There were no significant improvements in admission temperatures or SPO₂ targeting. When 7 vs 0 items of pre-delivery preparedness were completed, we saw improvements in thermoregulation (57% vs 72%), SPO₂ targeting (60% vs 78%) and DCC compliance (43 to 67%).

CONCLUSION

Promoting teamwork by increasing pre-delivery preparedness is associated with improvement of thermoregulation, SPO₂ targeting and DCC compliance.

Using the Delphi method to develop nursing-sensitive quality indicators for the NICU

AIMS AND OBJECTIVES

To develop nursing-sensitive quality indicators consistent with current medical practices in Chinese neonatal intensive care units.

BACKGROUND

The development of nursing-sensitive quality indicators has become a top priority in nursing management. To the best of our knowledge, there has been no objective, scientific and sensitive evaluation of the quality of neonatal intensive care unit nursing in China.

DESIGN

A modified Delphi technique was used to seek opinions from experts about what should be used and prioritised as indicators of quality care in neonatal intensive care unit nursing.

METHODS

Based on a literature review, we identified 21 indicators of nursing-sensitive quality in the neonatal intensive care unit. Our group of 11 consultants chose 13 indicators to be discussed using the Delphi method. In October and November 2014, 39 neonatal intensive care unit experts in 18 tertiary hospitals spread across six provinces participated in two rounds of Delphi panels.

RESULTS

Of the 13 indicators discussed, 11 were identified as indicators of nursing-sensitive quality in the neonatal intensive care unit: rate of nosocomial infections, rate of accidental endotracheal extubation, rate of errors in medication administration, rate of treatment for pain, rate of peripheral venous extravasation, rate of compliance with handwashing techniques, incidence of pressure ulcers, incidence of noise, the bed-to-care ratio, the proportion of nurses with greater than five years neonatal intensive care unit experience and incidence of retinopathy.

CONCLUSIONS

The 11 neonatal intensive care unit nursing-sensitive indicators identified by the Delphi method integrated with basic Chinese practices provide a basis for nursing management and the monitoring of nursing quality.

RELEVANCE TO CLINICAL PRACTICE

This study identified nursing-sensitive quality indicators for neonatal intensive care unit care that are suitable for current clinical practice in China.

The neonatal preventable harm index: a high reliability tool

OBJECTIVE

The aim of this study is to identify, quantify and disseminate a novel set of safety indicators for monitoring the occurrence of preventable harm in the neonatal intensive care unit (NICU).

STUDY DESIGN

Literature review and experiences in an academic, level IV NICU identified prevalent, preventable safety events: hospital-acquired infections (catheter-associated bloodstream infection, ventilator-associated pneumonia), unscheduled extubations, intravenous infiltrates requiring intervention, first week readmissions, serious adverse drug events and miscellaneous events (unanticipated harm or serious near misses). Negative binominal regression evaluated the event incidence trends.

RESULTS

Of 226 preventable harm events occurring between March 2013 and January 2015, the most common were unscheduled extubations (98; 2/100 ventilator days) and intravenous infiltrates (62; 2.7/100 admissions). No trends were detected (rate ratio: 0.99; confidence limits: 0.96 to 1.01; P=0.38).

CONCLUSION

The Neonatal Preventable Harm Index represents a novel and transparent means to monitor serious safety events and direct harm prevention strategies in the NICU.

Factors influencing a nurse's decision to question medication administration in a neonatal clinical care unit

AIMS AND OBJECTIVES

The aim of this study was to identify factors that influence nurse's decisions to question concerning aspects of medication administration within the context of a neonatal clinical care unit.

BACKGROUND

Medication error in the neonatal setting can be high with this particularly vulnerable population. As the care giver responsible for medication administration, nurses are deemed accountable for most errors. However, they are recognised as the forefront of prevention. Minimal evidence is available around reasoning, decision making and questioning around medication administration. Therefore, this study focuses upon addressing the gap in knowledge around what nurses believe influences their decision to question.

DESIGN

A critical incident design was employed where nurses were asked to describe clinical incidents around their decision to question a medication issue. Nurses were recruited from a neonatal clinical care unit and participated in an individual digitally recorded interview.

RESULTS

One hundred and three nurses participated between December 2013-August 2014. Use of the constant comparative method revealed commonalities within transcripts. Thirty-six categories were grouped into three major themes: 'Working environment', 'Doing the right thing' and 'Knowledge about medications'.

CONCLUSIONS

Findings highlight factors that influence nurses' decision to question issues around medication administration. Nurses feel it is their responsibility to do the right thing and speak up for their vulnerable patients to enhance patient safety. Negative dimensions within the themes will inform planning of educational strategies to improve patient safety, whereas positive dimensions must be reinforced within the multidisciplinary team.

RELEVANCE TO CLINICAL PRACTICE

The working environment must support nurses to question and ultimately provide safe patient care. Clear and up to date policies, formal and informal education, role modelling by senior nurses, effective use of communication skills and a team approach can facilitate nurses to appropriately question aspects around medication administration.

The Journey to High Reliability in the NICU

Neonatal intensive care units (NICUs) are at high risk for medical errors due to the population, setting, and complexity of care. Furthermore, "near misses" often precede actual errors yet are mostly underreported and unrecognized as safety concerns. There is a growing recognition that a systems approach to quality and safety is foundational to improving care at the bedside and patient outcomes. The High Reliability Organization model is one such approach. It recognizes the challenges of a highly complex system and combines this recognition with a continual emphasis on reducing errors. Although the principles of the High Reliability Organization hold promise in accelerating quality and safety in the NICU, it is imperative that nurses at the bedside as well as nurse leaders actually learn how to operationalize high reliability principles and strategies that lead to better outcomes. This article outlines the necessary principles, culture, strategies, and behaviors that NICU nurses and nurse leaders must adopt to achieve high reliability in their units.

Using smart pumps to reduce medication errors in the NICU

Infants in the neonatal intensive care unit (NICU) are considered one of the most vulnerable patient populations, and medication errors in this population can result in devastating, life-threatening consequences. The use of "smart pump" technology has the potential to minimize risk of error by providing safety measures before medication administration. Successful integration of smart pumps requires a clear communication plan to facilitate staff education and acceptance of advanced technology systems. Unit adoption of smart pumps can enhance patient safety while supporting the implementation of evidenced-based practices in nursing care.

P.U.R.E. Communication: A Strategy to Improve Care-Coordination for High Risk Birth

High-risk birth can be an emotionally-charged and sometimes emergent event that requires a cohesive multidisciplinary team. Communication breakdowns in perinatal emergencies are known to contribute to errors and adverse patient outcomes. One approach to breaching these barriers is the Purposeful, Unambiguous, Respectful, and Effective, P.U.R.E. process. P.U.R.E. is a method of communication that emphasizes coordination and recognizes the contributions of each member of the team. The purpose of this article is to describe how the P.U.R.E. process works and how teamwork strategies, group skills training, and structured communication techniques complement it.

Failure to rescue in neonatal care

Failure to rescue (FTR) has been described as the end result of a series of events relating to the environment of care and nursing quality. Only recently has FTR as a process measure been applied to perinatal care settings. Nurses' continuous presence at the bedside puts them in a privileged position to recognize signs of clinical deterioration and to take action. Many factors contribute to nurses' ability to save lives when infants develop complications. Although such factors are often system-related, nurses may be held responsible if they do not act according to an acceptable standard of care. In the neonatal intensive care unit, FTR has not been applied or adopted as a measure of nursing quality. This article describes how FTR is relevant in the neonatal intensive care unit and outlines nursing and system actions that can be taken to rescue some of the hospital's most vulnerable patients.