Random Safety Auditing, Root Cause Analysis, Failure Mode and Effects Analysis

Patient safety is a worldwide priority aimed at preventing medical errors before they cause death, harm, or injury. Medical errors impact 1 in 10 patients worldwide (WHO), and their implications may include death, permanent, or temporary harm, financial loss, and psychosocial harm to the patient and in some cases to the caregiver. The unique aspects and the complexity of the neonatal intensive (NICU) environment, in addition to the vulnerability of the neonatal population increase the risk for medical errors. The following article offers an overview of safety issues specific to neonatal intensive care and provides strategies and examples on how to ensure safe practice. In particular, the authors focus on strategies to improve the team process. Practice recommendations and research implications are presented.

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“…Care/Quality Network (NIC/Q) and real time safety audits 21 Provide a guide to review system related-human factors with real-time inspection.…”

Section: Heuristic Checklists Series By the Von Neonatal Intensivementioning

confidence: 99%

Patient Safety in the NICU

Samra

McGrath

Rollins

2011

Journal of Perinatal &Amp; Neonatal Nursing

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“…Local institutions may address these deficiencies by using established quality improvement methods, such as the Model for Improvement, 39 or waste elimination techniques, such as Lean. 40 These approaches may require innovative tools, 41 as well as multidisciplinary education focused on value in neonatal care. 42 …”

Section: Discussionmentioning

confidence: 99%

Choosing Wisely in Newborn Medicine: Five Opportunities to Increase Value

et al. 2015

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BACKGROUND: The use of unnecessary tests and treatments contributes to health care waste. The “Choosing Wisely” campaign charges medical societies with identifying such items. This report describes the identification of 5 tests and treatments in newborn medicine. METHODS: A national survey identified candidate tests and treatments. An expert panel of 51 individuals representing 28 perinatal care organizations narrowed the list over 3 rounds of a modified Delphi process. In the final round, the panel was provided with Grading of Recommendation, Assessment, Development and Evaluation (GRADE) literature summaries of the top 12 tests and treatments. RESULTS: A total of 1648 candidate tests and 1222 treatments were suggested by 1047 survey respondents. After 3 Delphi rounds, the expert panel achieved consensus on the following top 5 items: (1) avoid routine use of antireflux medications for treatment of symptomatic gastroesophageal reflux disease or for treatment of apnea and desaturation in preterm infants, (2) avoid routine continuation of antibiotic therapy beyond 48 hours for initially asymptomatic infants without evidence of bacterial infection, (3) avoid routine use of pneumograms for predischarge assessment of ongoing and/or prolonged apnea of prematurity, (4) avoid routine daily chest radiographs without an indication for intubated infants, and (5) avoid routine screening term-equivalent or discharge brain MRIs in preterm infants. CONCLUSIONS: The Choosing Wisely Top Five for newborn medicine highlights tests and treatments that cannot be adequately justified on the basis of efficacy, safety, or cost. This list serves as a starting point for quality improvement efforts to optimize both clinical outcomes and resource utilization in newborn care.

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“…Several studies have shown that these events are more frequent and serious in newborns. [5][6][7] Retrospective, observational studies have shown that errors and deviations from the neonatal CPR guidelines are common. In one study, the resuscitation team members committed 152 errors in 547 CPR guidelines steps (an average error rate of 27.8%).…”

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confidence: 99%

“…1,3 Random real-time safety audits (RRTSAs) are a safety tool widely used in high-risk industries because they efficiently identify errors and hazard situations, thus making prevention of these risks possible. 7,10 Checklists are compiled for each of several preidentified error-prone activities. To perform the audit, a checklist of a certain process is chosen at random and the auditors then go to that point in the process to immediate assess and review the work in progress relative to the checklist endpoints.…”

mentioning

confidence: 99%

Real-Time Safety Audits of Neonatal Delivery Room Resuscitation Areas: Are We Sufficiently Prepared?

Ortiz-Movilla

Funes-Moñux²,

Domingo-Comeche

et al. 2020

Am J Perinatol

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Objective This study aimed to use real-time safety audits to establish whether preparation of the equipment required for the stabilization and resuscitation of newborns in the delivery room areas is adequate. Study Design This was a descriptive, multicenter study performed at five-level III-A neonatal units in Madrid, Spain. For 1 year, one researcher from each center performed random real-time safety audits (RRTSAs), on different days and during different shifts, of at least three neonatal stabilization areas, either in the delivery room or in the operating room used for caesarean sections. Three factors in each area were reviewed: the set-up of the radiant warmer, the materials, and medication available. The global audit was considered without defect when no errors were detected in any of the audited factors. Possible differences in the results were analyzed as a function of the study month, day of the week, or shift during which the audit had been performed. Results A total of 852 audits were performed. No defects were detected in any of the three factors analyzed in the 534 (62.7%, 95% confidence interval [CI]: 59.3–65.9) cases. Slight defects were detected in 98 (11.5%, 95% CI: 9.4–13.8) cases and serious defects capable of producing adverse events in the newborn during resuscitation were found in 220 (25.8%, 95% CI: 22.9–28.9) cases. No statistically significant differences in the results were found according to the day of the week or time during which the audits were performed. However, the percentage of RRTSAs without defect increased as the study period progressed (first quarter 38.1% vs. the last quarter 84.2%; p < 0.001). Conclusion The percentage of adequately prepared resuscitation areas was low. RRTSAs made it possible to detect errors in the correct availability of the neonatal stabilization areas and improved their preparation by preventing errors from being perpetuated over time. Key Points

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Random Safety Auditing, Root Cause Analysis, Failure Mode and Effects Analysis

Cited by 31 publications

References 32 publications

Patient Safety in the NICU

Patient Safety in the NICU

Choosing Wisely in Newborn Medicine: Five Opportunities to Increase Value

Real-Time Safety Audits of Neonatal Delivery Room Resuscitation Areas: Are We Sufficiently Prepared?

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