Quality improvement (QI) is now a central part of the work of clinicians throughout healthcare. It is based on clear scientific principles, a valid way of measuring change and has theories of reliability and human factors that underpin the interventions. The Neonatal Intensive Care Unit (NICU) is a highly complex adaptive system that lends itself to the application of QI principles. This will require the development of a safety culture that continually seeks to improve. Clinicians and all those who work in NICU will require training in the methodologies of QI and patient safety to effect change. Working together in collaborative networks can accelerate change. In this paper we discuss some of the key concepts and provide some examples of improvement in the NICU.

BackgroundRandomised control trial (RCT)-derived survival figures for acute exacerbation of chronic obstructive pulmonary disease admissions managed with non-invasive ventilation (NIV) have not been replicated in UK clinical audits. Subsequent guidelines have emphasised the need for timely NIV application.MethodsData from the 2008 and 2014 national chronic obstructive pulmonary disease audits was used to analyse the association between time to NIV and mortalityResults1032 patients received NIV in 2008, and 1612 in 2014. Overall mortality rates reduced between the audits from 24.9% in 2008 to 16.8% in 2014 but time to NIV lengthened. In 2014, 20.9% of patients received NIV within 60 min versus 24.9% in 2008 (p=0.001). The proportion of patients receiving NIV between 3 and 24 hours increased from 31.3% in 2008 to 39% in 2014 (p=0.001). Patients admitted with hypercapnic acidotic respiratory failure who received NIV within 3 hours had lower in-patient mortality than those who received NIV between 3 and 24 hours, 15.9% versus 18.4%, but this did not reach statistical significance (p=0.425), but acidotic patients receiving NIV >24 hours after admission had significantly higher mortality (28.9%, p=0.002). A second cohort admitted with hypercapnia but normal range pH, who developed later acidosis, had higher mortality (24.6%), compared with those acidotic on admission (18% p≤0.001) and an extremely high mortality when NIV was given >24 hours after admission (42.6%).ConclusionSurvival rates for those treated with NIV has improved between the two audits but remains lower than reported in RCTs. Patients who developed acidosis after admission and received NIV later in the hospital stay have even higher mortality and deserve further study and clinical attention.

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People with mental health conditions are at a specific risk of harm when in healthcare. Mental health and well-being are often not given the same priority as physical health. The type of risk to the individual is dependent on the context, which can be a mental health facility or a general hospital. The main areas of concern are self-harm, including suicide, delayed diagnosis, misdiagnosis, and medication harm. These risks are amplified in health facilities that do not have the skills to meet the needs of individuals with mental health problems in appropriate environments. In non-mental health facilities, proactive action can prevent harm by assessing the environment, the organizational culture, and attitudes to mental health, as well as the skills of the staff. Care should be personalized and person-centred, should focus on recovery and trauma prevention, and should be culturally responsive.