Improving the Safety of Neonatal Care Through the Development and Implementation of a Staff-Focused Delta Team

Abstract

Patient safety is one of the greatest imperatives in healthcare today, yet there are many obstacles that must be overcome to make healthcare delivery truly safe. Critically ill newborns are among the most medically fragile patients in hospitals today. Given their size and gestational age, the tolerance for error within this population is extremely small. Medical errors that may be less consequential in adults can be disastrous for infants. Developing a culture of safety demands a mind-set that continuously seeks out vulnerabilities and prospectively addresses them through systems-based rather than individual-based solutions. The complexities of clinical care and intricacies of human behavior may prevent total elimination of risk, but caregivers are in a position to develop a culture of safety that can minimize risks for adverse events in the neonatal intensive care unit. Specific strategies used to successfully implement a staff-focused patient safety program are described in this article. These strategies include the development of systemwide and unit-based interdisciplinary safety teams to proactively identify and address safety concerns, development of specific tools and techniques used for analysis and prioritization of risk, resources that teams used to support an environment of safety; and implementation of staff-driven solutions to address safety concerns.

Eventos adversos en recién nacidos hospitalizados en una Unidad de Cuidados Intermedios

“…El cuidado de la salud ha evolucionado notablemente en diversos aspectos, incluido el ámbito tecnológico que, si bien es cierto, ha logrado reducir significativamente la morbimortalidad de la población en general, trae consigo un incremento en el riesgo de aparición de ciertas complicaciones 2 . Según diversos estudios, una de las poblaciones más vulnerables son los recién nacidos, debido a que, por sus propias características físicas y fisiológicas como la edad gestacional y peso, requieren una atención multidisciplinaria de mayor complejidad y una mayor estancia hospitalaria [3][4][5] .…”

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

“…Neonatal safety research has largely been limited to a narrow catalog of error types (e.g., medication and diagnostic errors) [23][24][25] and interventions (error reporting, team training). [26][27][28][29] Few studies have investigated the etiology or effective prevention of all-cause harm in neonatal care. 12 Failing to do so incompletely maps the sources of potential harm and limits the range of interventions considered and, consequently, also circumscribes the efficacy of interventions for improving safety.…”

“…Neonatal safety research has largely been limited to a narrow catalog of error types (e.g., medication and diagnostic errors) 23–25 and interventions (error reporting, team training) 26–29 . Few studies have investigated the etiology or effective prevention of all-cause harm in neonatal care 12 .…”