Gautham Suresh

Adverse Events in the Neonatal Intensive Care Unit: Development, Testing, and Findings of an NICU-Focused Trigger Tool to Identify Harm in North American NICUs

OBJECTIVES. Currently there are few practical methods to identify and measure harm to hospitalized children. Patients in NICUs are at high risk and warrant a detailed assessment of harm to guide patient safety efforts. The purpose of this work was to develop a NICU-focused tool for adverse event detection and to describe the incidence of adverse events in NICUs identified by this tool. METHODS. A NICU-focused trigger tool for adverse event detection was developed and tested. Fifty patients from each site with a minimum 2-day NICU stay were randomly selected. All adverse events identified using the trigger tool were evaluated for severity, preventability, ability to mitigate, ability to identify the event earlier, and presence of associated occurrence report. Each trigger, and the entire tool, was evaluated for positive predictive value. Study chart reviewers, in aggregate, identified 88.0% of all potential triggers and 92.4% of all potential adverse events. RESULTS. Review of 749 randomly selected charts from 15 NICUs revealed 2218 triggers or 2.96 per patient, and 554 unique adverse events or 0.74 per patient. The positive predictive value of the trigger tool was 0.38. Adverse event rates were higher for patients <28 weeks gestation and <1500 g birth weight. Fifty-six percent of all adverse events were deemed preventable; 16% could have been identified earlier, and 6% could have been mitigated more effectively. Only 8% of adverse events were identified in existing hospital-based occurrence reports. The most common adverse events identified were nosocomial infections, catheter infiltrates, and abnormal cranial imaging. CONCLUSIONS. Adverse event rates in the NICU setting are substantially higher than previously described. Many adverse events resulted in permanent harm and the majority were classified as preventable. Only 8% were identified using traditional voluntary reporting methods. Our NICU-focused trigger tool appears efficient and effective at identifying adverse events.

Real time patient safety audits: improving safety every day

Background: Timely error detection including feedback to clinical staff is a prerequisite for focused improvement in patient safety. Real time auditing, the efficacy of which has been repeatedly demonstrated in industry, has not been used previously to evaluate patient safety. Methods successful at improving quality and safety in industry may provide avenues for improvement in patient safety. Objective: Pilot study to determine the feasibility and utility of real time safety auditing during routine clinical work in an intensive care unit (ICU). Methods: A 36 item patient safety checklist was developed via a modified Delphi technique. The checklist focused on errors associated with delays in care, equipment failure, diagnostic studies, information transfer and non-compliance with hospital policy. Safety audits were performed using the checklist during and after morning work rounds thrice weekly during the 5 week study period from January to March 2003. Results: A total of 338 errors were detected; 27 (75%) of the 36 items on the checklist detected ⩾1 error. Diverse error types were found including unlabeled medication at the bedside (nu200a=u200a31), ID band missing or in an inappropriate location (nu200a=u200a70), inappropriate pulse oximeter alarm setting (nu200a=u200a22), and delay in communication/information transfer that led to a delay in appropriate care (nu200a=u200a4). Conclusions: Real time safety audits performed during routine work can detect a broad range of errors. Significant safety problems were detected promptly, leading to rapid changes in policy and practice. Staff acceptance was facilitated by fostering a blame free “culture of patient safety” involving clinical personnel in detection of remediable gaps in performance, and limiting the burden of data collection.

Patient Misidentification in the Neonatal Intensive Care Unit: Quantification of Risk

OBJECTIVE. To quantify the potential for misidentification among NICU patients resulting from similarities in patient names or hospital medical record numbers (MRNs). METHODS. A listing of all patients who received care in 1 NICU during 1 calendar year was obtained from the units electronic medical record system. A patient day was considered at risk for misidentification when the index patient shared a surname, similar-sounding surname, or similar MRN with another patient who was cared for in the NICU on that day. RESULTS. During the 1-year study period, 12186 days of patient care were provided to 1260 patients. The units average daily census was 33.4; the maximum census was 48. Not a single day was free of risk for patient misidentification. The mean number of patients who were at risk on any given day was 17 (range: 5–35), representing just over 50% of the average daily census. During the entire calendar year, the risk ranged from 20.6% to a high of 72.9% of the average daily census. The most common causes of misidentification risk were similar-appearing MRNs (44% of patient days). Identical surnames were present in 34% of patient days, and similar-sounding names were present in 9.7% of days. Twins and triplets contributed one third of patient days in the NICU. After these multiple births were excluded from analysis, 26.3% of patient days remained at risk for misidentification. Among singletons, the contribution to misidentification risk of similar-sounding surnames was relatively unchanged (9.1% of patient days), whereas that of similar MRNs and identical surnames decreased (17.6% and 1.0%, respectively). CONCLUSIONS. NICU patients are frequently at risk for misidentification errors as a result of similarities in standard identifiers. This risk persists even after exclusion of multiple births and is substantially higher than has been reported in other hospitalized populations.

Cost-Effectiveness of Strategies That Are Intended to Prevent Kernicterus in Newborn Infants

Objective. There is concern about an increasing incidence of kernicterus in healthy term neonates in the United States. Although the incidence of kernicterus is unknown, several potential strategies that are intended to prevent kernicterus have been proposed by experts. It is necessary to assess the costs, benefits, and risks of such strategies before widespread policy changes are made. The objective of this study was to determine the direct costs to prevent a case of kernicterus with the following 3 strategies: (1) universal follow-up in the office or at home within 1 to 2 days of early newborn discharge, (2) routine predischarge serum bilirubin with selective follow-up and laboratory testing, and (3) routine predischarge transcutaneous bilirubin with selective follow-up and laboratory testing. Methods. We performed an incremental cost-effectiveness analysis of the 3 strategies compared with current practice. We used a decision analytic model and a spreadsheet to estimate the direct costs and outcomes, including the savings resulting from prevented kernicterus, for an annual cohort of 2 800 000 healthy term newborns who are eligible for early discharge. We used a modified societal perspective and 2002 US dollars. With each strategy, the test and treatment thresholds for hyperbilirubinemia are lowered compared with current practice. Results. With the base-case assumptions (current incidence of kernicterus 1:100 000 and a relative risk reduction [RRR] of 0.7 with each strategy), the cost to prevent 1 case of kernicterus was

Patient safety in the context of neonatal intensive care: research and educational opportunities.

10 321 463,

Evaluation and Development of Potentially Better Practices for Perinatal and Neonatal Communication and Collaboration

5 743 905, and

Central line-associated bloodstream infections in neonatal intensive care: changing the mental model from inevitability to preventability.

9 191 352 respectively for strategies 1, 2, and 3 listed above. The total annual incremental costs for the cohort were, respectively,

Attitudes of Obstetric and Pediatric Health Care Providers Toward Resuscitation of Infants Who Are Born at the Margins of Viability

202 300 671,

Preterm Versus Term Children: Analysis of Sedation/Anesthesia Adverse Events and Longitudinal Risk.

112 580 535, and

Implementation and case-study results of potentially better practices for collaboration between obstetrics and neonatology to achieve improved perinatal outcomes.

180 150 494. Sensitivity analyses showed that the cost per case is highly dependent on the population incidence of kernicterus and the RRR with each strategy, both of which are currently unknown. In our model, annual cost savings of