LWW/JPNN JPN200170 April 28, 2011 19:46

DOI: 10.1097/JPN.0b013e31821693b2

J Perinat Neonat Nurs r Volume 25 Number 2, 123–132 r Copyright 

C 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Patient Safety in the NICU

A Comprehensive Review
Haifa A. Samra, PhD, RN-NIC; Jacqueline M. McGrath, PhD, RN, FNAP, FAAN;
Whitney Rollins, BS, RN

ABSTRACT safety in the neonatal intensive care unit (NICU). In par-

Patient safety is a worldwide priority aimed at preventing ticular, improving the team process is a pivotal focus in
medical errors before they cause death, harm, or injury. this review as well as practice and research implications
Medical errors impact 1 in 10 patients worldwide (WHO), related to patient safety.
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 SCOPE OF THE PROBLEM
unique aspects and the complexity of the neonatal inten- Medication errors occur more frequently in premature
sive (NICU) environment, in addition to the vulnerability of neonates especially those born less than 30 weeks ges-
the neonatal population increase the risk for medical errors. tation and weighing less than 1500 gm. These infants
The following article offers an overview of safety issues are at great risk because of their severity of illness and
specific to neonatal intensive care and provides strategies the need for more medical support including pharmaco-
and examples on how to ensure safe practice. In particular, logic measures, cardiovascular monitoring, and support
the authors focus on strategies to improve the team pro- and nutritional measures. Recent reports show that 57%
cess. Practice recommendations and research implications of medical errors occur in 24 to 27 weeks gestation in-
are presented. fants compared with only 3% in hospitalized full-term
2
Key Words: adverse events, errors, NICU, neonatal, safety newborns. Adverse drug events occur at a rate of 13
2,3
to 91 events/100 neonatal intensive care admissions.
atient safety is a worldwide priority aimed at

P
Using the trigger method or an “occurrence” to prompt
preventing medical errors before they cause a focused chart review, high rates of medical errors are
death, harm, or injury. Medical errors impact often revealed in hospitalized adults and children. A re-
1
1 in 10 patients worldwide, and their implications may view of 749 randomly selected charts from 15 NICUs (14
include death, permanent or temporary harm, financial in the United States and 1 in Canada) showed that ad-
loss, and psychosocial harm to the patient and in some verse events (AE) (Table 1 for definitions) occur at a rate
4,5
cases to the caregiver. The purposes of this article are of 74 events per every 100 patients (0–11 AE/patient).
to (1) provide an overview of medical errors, (2) dis- Of the reported events, 10% resulted in death, 23% re-
cuss factors leading to medical errors and, (3) discuss sulted in permanent harm, 40% resulted in temporary
evidence-based strategies aimed at improving patient harm, and 7% required life-saving interventions. Over-
all, the report stated that 56% of the events could have
4
been prevented. Reports of AE in the NICU include,
Author Affiliation: College of Nursing, South Dakota State
University, Brookings (Dr Samra and Ms Rollins); and School of
but are not limited to, nosocomial infection (28%), in-
Nursing, Virginia Commonwealth University, Richmond (Dr McGrath). travenous catheter infiltrates (16%), accidental extuba-
The authors have no conflict of interest. tions (8%), and intracranial hemorrhage and ischemia
(10.5%). Misidentification errors are also common in
Corresponding Author: Haifa (Abou) Samra, College of Nursing,
South Dakota State University, Box 2275, SNF 209, Brookings, SD the NICU. For example, 11% of all errors submitted to
57007 ([email protected]). the Vermont Oxford Network (VON) are classified as
Submitted for publication: November 1, 2010; Accepted for publication: misidentification errors. One study showed that only 9%
January 31, 2011 of NICU patients wear identification bands as specified

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Table 1. Terminology and definitions5

Medical error: Any deviation from a set plan of action that causes failure to achieve intended medical outcomes
Safety: “freedom from accidental injury”
Adverse events: Undesirable or unintended events that take place during hospitalization. These events are that are not
related to the patient’s disease and results in injury or harm to a patient.
Sentinel events: Higher level adverse events or unexpected events that are not related to the patient illness and that
result in death, serious injury, or “risk thereof”
Adverse medication events: Medical errors or adverse events related to medication errors
Failure Mode Effect Analysis (FMEA): FMEA is a framework used to perform a prospective error analysis where the
likelihood of a process failing and the consequence of the failure are used to produce what is called a “criticality
index.” Steps in a process are ranked according to their indices and those with the highest indices are considered
apriority for quality improvement.
Root Cause (RCA): A retrospective approach to identify causes or contributing factors underlying adverse events. It
gives a detailed description of all events that have led to the error.
Red Rules: According to the AHRQ, red rules are “Rules that must be followed to the letter.” If there is a deviation from
the red rule all work stops until compliance with the rule is ensured.

by the Joint Commission (formerly Joint Commission care and patients should not be harmed by the care
8
on Accreditation of Healthcare Organization: JCAHO) that they receive. A third report by the IOM in 2003
6
unit policy. This policy infraction has implications for Keeping Patients Safe: Transforming the Work Environ-
diagnostic, medication, treatment, and documentation ment of Nurses, called on nurses to create a culture of
errors. Other countries such as Switzerland, England, safety and to construct safe workplace environments.
the Netherlands, Canada, and Australia report similar Fatigue and quality of staffing were highlighted as fac-
3 9
error rates. tors affecting patient safety. This priority for nursing is
congruent with the Nurses’ Code of Ethics that holds
nurses accountable for participating in the creation of
BACKGROUND AND SIGNIFICANCE work environments that are conducive to safe and qual-
In 1999, the Institute of Medicine (IOM) released ity care.
its landmark report, To Err is Human: Building a
Safer Health System, which stated that up to 98 000
deaths/year are attributable to medical errors with an
estimated cost of $17 to $29 billion. In addition to its call FACTORS LEADING TO MEDICAL ERRORS
on healthcare professionals to adopt evidence-based AND REASON’S “SWISS CHEESE” MODEL
strategies to improve teamwork and communication, Reliable work processes and constant vigilance by
the report heightened the awareness of the public, as healthcare professionals are crucial for safe provision of
well as policy makers, to patient safety issues. Although care in any NICU. Despite best efforts, an error can still
it diminished consumer confidence in the healthcare in- occur and error prevention requires more than just good
dustry, the IOM report called for Congress to investigate intentions. Medical errors in the workplace leading to
7
medical errors and improve patient safety. During the adverse events in the NICU are rarely intentional or the
last decade and since the release of the IOM report, result of one single factor. System structure and pro-
patient safety has become the focus of several pro- cesses that are not well designed and that do not take
fessional organizations and regulatory and accrediting into account human factors and workplace hazards are
agencies, as evidenced by the release of several patient prone to fail and therefore, leave people vulnerable to
safety initiatives, statements, goals, and campaigns. The committing errors. Multiple factors at several levels in-
Joint Commission National Safety Goals, the Institute cluding point of care, organization, patient, individual,
of Health Improvement 100 k lives Campaign, and the or team levels exist in patient care and management.
Safety and Quality Improvement Act of 2005 are among Because of the interconnectedness of these factors, fail-
those initiatives. In 2001, the IOM released another re- ure at one level of the system may affect reliability and
10
port Crossing the Quality Chasm: A New Health System performance at other levels. Factors at the point of
for the 21st Century that highlighted 6 safety and qual- care may include equipment and medical device poor
8
ity aims for the 21st Century. According to the report, design or malfunction. At the organization level, inade-
healthcare providers should offer effective, evidenced- quate staffing, look alike and sound alike drug names,
based, patient centered, timely, efficient, and equitable inadequate information sharing, cost-cutting measures,

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LWW/JPNN JPN200170 April 28, 2011 19:46

poor climate and environmental design, and manage-

ment practices contribute to medical error.
The unique aspects and the complexity of the NICU
environment, in addition to the vulnerability of the
neonatal population increase the risk for medical errors.
Medication errors pose a significant risk to the neona-
tal patient for a number of reasons. Fragile neonates
have limited capacity in buffering the unintended con-
sequences of their medical treatment and therefore can
be easily harmed. Prolonged lengths of hospital stay (ie,
sicker and more complicated patients) means longer ex-
posure to potential harm. The neonate’s rapidly chang-
ing body size and the use of off-label medications pose
Figure 1. The Swiss Cheese Model by James Reason pub-
challenges to healthcare professionals on a daily ba- lished in 2000. Adopted from Perneger BMC Health Ser-
sis. In addition, the neonate’s inability to communicate vices Research 2005 5:71.
what he or she is experiencing adds to the risk of suf-
fering from a severe adverse effect of a drug that has
been administered. Finally, premature and underdevel- To sum it up, work environments are complex and
oped body systems of the neonate who is admitted so is how and why medical errors occur. Reason’s
to the NICU interfere with drug absorption, distribu- Swiss Cheese Model (Figure 1) is the most widely used
tion, metabolism, and excretion, making the risk of model to explain system failure and to analyze medical
16
being exposed to toxic drug levels exponential com- errors. Every system has hazards that are inherent in
11
pared to an adult patient. Results from 20 commu- its structure. Every system also has defenses or barriers
nity hospitals participating in the Healthcare Utilization that prevent harm from a hazard reaching the patient.
Project (HCUP) of the Agency for Healthcare Research Hazards are conditions or events that are not related to
and Quality (AHRQ) showed that risk for medical er- the patient’s course of illness and have the potential to
ror is higher with longer length of stay, emergency cause harm if there is a failure in the system defenses.
type admissions, and for publically insured pediatric System defenses or barriers, like Swiss cheese slices,
patients.
12 have holes in them and if due to some random event
Human factors at an individual level include fatigue, those holes align, they form an open path for harm
burnout, lack of expertise and false sense of security from a workplace hazard or a medical error to reach
with technology, complacency, and lack of cultural the patient. Medical errors or unsafe acts can be seen
competence. Human factors at the team level are re- as holes in the system defenses. Humans are fallible
lated to team performance and to lack of effective lead- and medical errors are inevitable. However by adding
ership and team focus, failure to share information and layers of defense and by plugging the holes and pre-
provide task assistance and breakdown in communi- venting them from aligning to form a path, harm can
cation, which is believed to be the most significant be stopped from reaching the patient.
barrier to patient safety. According to the Joint Com-
mission, 70% to 80% of medical errors are due to dys- STRATEGIES TO IMPROVE PATIENT SAFETY
13
functional interactions. Cultural and sex differences Patient safety is a comprehensive approach that uses
may exacerbate communication problems and lead to human factors science to improve system processes and
a greater potential for breakdowns in communication. structure and to ensure patient safety. Several strategies
Certain behaviors that are displayed by individuals and have been developed and adopted by healthcare or-
by groups lead to communication breakdown, com- ganizations to strengthen barriers to medical error and
promise the team process, and therefore weaken the to eliminate workplace hazards. Table 2 for a list of
17−29
system defenses against medical errors. Such behaviors such strategies. Among those strategies, Electronic
include “excessive professional courtesy” (when team Medication Ordering or Computerized Provider Order
members are reluctant to challenge someone of higher Entry and Safety Medication Systems (Bar Coding) have
status), “hidden agendas”, “halo effect”, and “passenger made the most significant impact on reducing the rate
syndrome” (“just along for the ride”), and “task fixation” of AE. It is believed that 93% of adverse drug events are
14
or failure to see the big picture. In a large study of prevented due to the implementation of Computerized
healthcare providers, 7% of study participants reported Provider Order Entry. For example, barcode medication
making a medication error in the last year with intimi- administration has led to a 47% reduction in the rate of
15 20
dation by a coworker being the contributing factor. preventable adverse drug events.

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Table 2. Strategies to improve patient safety

Strategy Anticipated outcome

Evidence-based practices such as central line and Reduce incidence of healthcare-associated infection.
ventilator associated pneumonia bundles and Hand
washing17,18
Standardized resuscitation and stabilization of the Decrease neonatal mortality, chronic lung disease, and
neonate in the first hour of life (Golden Hour)17,19 length of stay
Computerized Provider Order Entry and Safety Reduce medication errors.
Medication Systems (Bar Coding)20
Failure Mode Effect analysis, Root Cause Analysis, Analyze, track errors.
Random Safety Analysis toolkits and checklists21 Establish trends, create learning opportunities.
The “Just Culture” Model22 Promote accountability but at the same time
acknowledge vulnerability of humans in committing
errors.
Ensure compliance with procedural rules.
Ensure congruence between organizational and individual
values.
Differentiate between unintentional and reckless
behavior.
Promote openness, transparency, fairness, and
knowledge.
Provides an algorithm for managing individuals and
systems when safety is compromised
Crew Resource Management and simulation23 Improve team communication and team process
Use resources efficiently.
Disclosure of incidents17 Reduce litigation and promote transparency.
Continuous quality improvement and Human Factor Improve quality and address practice issues.
Engineering24,25
Private room design and bedside reports26,27 Eliminating workplace hazards such as high levels of
noise and promoting family centered care.
Incentives and disincentives28 Stop payments for hospitals with negative consequences
of care or the never events. Reward hospitals with
reimbursement incentives.
Health literacy and cultural sensitivity17,29 Improve communication.
Heuristic checklists series by the VON Neonatal Intensive Provide a guide to review system related-human factors
Care/Quality Network (NIC/Q) and real time safety with real-time inspection.
audits21
Ensure system reliability.
Red rules30 Zero tolerance to deviation from procedural rules and
policies that are supported by evidence, clear,
measurable, and communicated to the staff throughout
the organization
Quality tools and tips from the Agency for Health Provide evidence-based checklists and items to improve
Research and Quality pediatric safety.
http://www.ahrq.gov/consumer/20tipkid.htm
Error management & Reporting systems Report, track, and preventing errors.
Anonymous and specialty-based external reporting Identify near misses
systems by NIC/Q web-based
Internal reporting systems within organizations, State Share information among organizations and create
mandatory reporting and National Patient Safety learning opportunities
Network

Technology alone cannot rectify all of the problems and “near misses.” In addition to providing informa-
leading to medical errors. Error management that in- tion on how effective certain strategies are in improving
cludes reporting, monitoring, tracking, and prevention patient safety, error reporting creates opportunities for
is the cornerstone for building safe patient environ- the staff and administration to learn from mistakes and
ments. Error reporting and tracking is an effective strat- to improve existing practices or create new strategies
egy in identifying trends and patterns of harmful events for decreasing the probability of harm. Several systems

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LWW/JPNN JPN200170 April 28, 2011 19:46

for error reporting exist (Table 2). Voluntary report- the crew; and to promote effective use of resources
ing whether external or internal generates most of the through the use of checklists, structured briefs or team
existing information on factors leading to error. Anony- events, advocacy and assertion. Even though the use
mous and specialty-based external reporting systems of CRM in the healthcare industry is still in its infancy,
such as the Neonatal Intensive Care Quality (NICQ) Col- promising results in improving patient safety has been
14
laborative sponsored by the Vermont Oxford Network reported. TeamSTEPPs emphasizes 4 core competen-
(web-based) provides opportunities for incident moni- cies with tools and scripts specific to each compe-
toring and generates a significant amount of important tency that are essential for reliable and high level team
information on trends and contributing factors. Inter- performance. The competencies are leadership, situa-
nal reporting systems increase awareness and create tion awareness (mutual performance monitoring), mu-
learning opportunities within the healthcare organiza- tual support (back-up behavior), and communication
tion. Some states require healthcare organizations to (Table 3). A paradigm shift from individual focus to
have patient safety plans in place and report serious team focus is believed to occur with TeamSTEPPS train-
events and incidents to state safety authorities. The ma- ing. The outcomes include focus on team competen-
14
jority of states prohibit punitive actions against health- cies, information sharing, and task assistance. Various
care workers reporting such events. Despite the avail- teams exist in a healthcare organization with different
ability of multiple reporting systems, existing data show professional backgrounds, responsibilities, and clinical
that the majority of incidents or events are not reported focus. Patient safety requires that teams and individuals
and patient safety remains of great concern. Barriers to within an organization be committed to coordination,
error reporting include cost, access to databases and collaboration, mutual accountability, acknowledgment,
lack of standardized terminology, and fear of punitive recognition, mutual respect, and partnership with the
actions. Building work cultures that support informa- patient and the family. Partnering with the NICU fam-
tion sharing, encourage and promote transparency, and ily is crucial for patient safety. The family needs to be
acknowledge human fallibility requires commitment, asked about their desire to be involved in their infant’s
trust, and resources. care, and their preferences must be respected. Families
A common understanding on how and why medical need to have access to relevant information about their
errors occur is needed. Safety interventions should not infants, and their feedback should be solicited. Leaving
be perceived as additional work or external mandates. the family out may leave out valuable information that
34
Instead, individuals must feel empowered to identify is crucial for providing safe care.
hazards in the work place and to implement strategies
that would eliminate or minimize those hazards. This
can be best achieved by building high performance PRACTICE RECOMMENDATIONS
14 31−33
teams and maximizing the team process. , Work culture is the sum of individual values, behav-
iors, and beliefs that are constantly displayed by the
team. Communication and behavior patterns exhibited
TEAMWORK, LEADERSHIP, WORK CULTURE by healthcare teams determine the workplace culture.
AND PATIENT SAFETY One of the initial steps toward building a culture of pa-
Team Strategies and Tools to Enhance Performance and tient safety is to create a vision that strives to achieve
Patient Safety (TeamSTEPPS) is an evidence-based pro- the highest level of team competence. Buying into such
gram developed by the Department of Defense (DoD) a vision, implementing it, and sustaining the changes
in collaboration with the Agency of Health Research can be challenging and requires resources and organi-
and Quality (AHRQ) to improve patient safety and build zational commitment. However, physicians and nurses
high efficiency reliable teams. Implementation of this have the obligation to provide the highest level of care
program has gained some momentum in the past few possible, do no harm, and maximize patient benefits.
years, is built on over 3 decades of research in the mil- By adopting the strategies that are shown in Table 4,
itary and offers a comprehensive approach to effective physicians and nurses can take the initiative to improve
14,33
teamwork. The TeamSTEPPS program is based on teamwork and ensure patient safety.
both the “Just Culture Model” and the Crew Resources
Management (CRM) concepts. Just Culture encourages
everyone who is involved in patient care to voice his RESEARCH IMPLICATIONS
or her safety concerns regardless of his or her posi- Even though during the last decade technological ad-
tion or status. The CRM has been used in the avia- vances and evidence-based practices have made posi-
tion industry for more than 2 decades. The aim is to tive impact on patient safety, the goal to build a safer
improve teamwork knowledge, skills, and attitudes of healthcare system has yet to be realized. The AHRQ’s

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Table 3. The TeamSTEPPS four team competencies

Competency Skills Scenarios and examples

Leadership Organize, build, and promote teamwork. Team Events: Briefs are used at the beginning
Identify and articulate goals of a shift or a patient care event to:
Make decisions and plan activities in -Identify who is on the team
collaboration with other team members. -Clarify roles and expectations
Enable team members to challenge and speak -Agree on plan of action
up when needed. -Make resources available
Manage and resolve conflicts. -Discuss and agree on workload
Delegate, and give feedback. Huddles are used at any time during a shift or a
Outcomes patient care event as Ad-hoc meetings to:
Information sharing -Solve problem
Effective management of resources. -Re-establish situation awareness
Effective communication and equitable -Reassess assignments, or readjust plan
workload of care
Strategies/Tools Debriefs are used at the end of a shift or care
Hold team events such as event such as a code to Informally exchange
Briefs information and review actions for the
Huddles purpose of improving the team process
Debriefs Use by answering the following questions:
-Was communication clear?
-Were roles and responsibilities clear?
-Was workload distribution equitable and
was task assistance provided?
-Were resources adequate?
-What went well and what did not and what
can be improved?
Situation Scan the work environment for conditions or STEP: The respiratory therapist noted that the
Awareness factors that affect patient safety baby’s HR is increased (STATUS). The baby’s
Watch each other’s back and cross monitor primary nurse is on lunch break (TEAM
each other actions MEMBERS). There is an admission on the
Correct each other actions unit and everyone is busy (ENVIRONMENT).
Make sure procedural laws are followed The therapist reports the baby’s status to the
Outcomes care coordinator (PROGRESS).
Situation awareness is maintained
Overload situations and stress are prevented
Workload is equitable.
Needed information is shared among team
members.
Errors are prevented.
Timely response to changes in the care
environment.
Team members are encouraged and motivated
to do their jobs to the best of their abilities.
Strategies/Tools
Use the STEP process to maintain situation
awareness and scan the environment and
this includes:
S = Assess Status of the patient
(Bio-psycho-social assessment)
T = Cross monitor your Team (fatigue, work
overload, stress, drugs, skill level, task
performance, medication, basic needs
including elimination and eating)
(continues)

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Table 3. The TeamSTEPPS four team competencies (Continued)

Competency Skills Scenarios and examples

E = Scan the Environment for hazards
(information related to the organization,
triage acuity, equipment, transport
status, pending admissions, etc.)
P = Evaluate Progress toward goal (Is the
plan of care for your patient appropriate,
is the family being informed of the plan
of care, are patient interventions,
treatments, etc. being completed.
Mutual Support Eliminate or minimize work stresses. Task assistance: One of the nurses is having
Provide and receive assistance and support a hard time starting an IV on one of her
each other. patients. You say” I noticed you are having
Eliminate hazards or factors that increase difficulty with this intravenous catheter
chances of error. start. It must be a difficult one. I have
Provide feedback both positive and constructive. 20–30 minutes of down time. How do you
Challenge unsafe practices and failure to like me to help? Can I call the practitioner
follow procedural rules. and start getting ready for a PICC line
Advocate for the patient insertion?
Outcomes Feedback: You heard one of the nurses
Better working relationships talking to a parent who is very upset and is
Ongoing growth and improvement. unhappy with the care her baby is
Elimination of hazards and high-risk situations. receiving. After conversing with the nurse,
Effective conflict management with a win-win the mother seems to calm done and does
outcome not appear to be angry anymore. Later,
Focus is maintained on the patient and patient you approach the nurse and you tell her
care. that you think she did a great job handled
the situation. Providing feedback rewards
Strategies/Tools and enforces the nurse’s. positive
Use advocacy and Assertion to manage conflict behavior, helps build trust and motivates
that is related to care decisions. and fosters teamwork.
Use the CUS tool and the 2-Rule Challenge to
resolve personal conflict CUS and the 2-challenge rule: A practitioner
• -C = I am Concerned ordered the wrong medication dose. You
• -U = I am Uncomfortable questioned her decision, yet she wants
• -S = This is a Safety issue you to go head and give the dose anyway.
The 2-Rule Challenge: is when you voice What do you do?
concern twice using CUS and if response In a firm and respectful manner you say that
remains unacceptable, utilize chain of you are concerned about the safety of the
command patient and that you are uncomfortable
Use DESC with I statements to resolve giving the ordered dose. You have spoken
personal conflict with the pharmacist and you would like the
• D = Describe a specific situation practitioner to reconsider the dose. If the
• E = Express how situation makes you feel practitioner insists on giving the
• S = Suggest other alternatives medication, repeat your concern, or have
• C = Consequences the pharmacist repeat it. If the conflict is
not resolved, document what you found,
refuse to give the medication and report to
your supervisor.
DESC: The physician was upset because the
lab draw on the infant that you were taking
care of was not done by the night shift
nurse. He started yelling and using
profound language in front of the parent.
How do you handle the situation?
Talk to the physician in private.
(continues)

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Table 3. The TeamSTEPPS four team competencies (Continued)

Competency Skills Scenarios and examples

D = Respectfully, tell the physician “I
understand the importance of having the
lab done and it is unfortunate that the
blood was not drawn by the nightshift
nurse.
E = However, yelling and screaming is
distracting and makes me feel intimidated.
S = I appreciate it more if next time you
come and ask for help in addressing the
issue. I appreciate it more if the problem is
addressed in a professional manner.
C = Yelling and screaming erodes the
family’s trust in us and makes us look as if
we do not care.

Communication Provide direct, concise, culturally SBAR: Baby Smith is having multiple apnea
sensitive, and timely communication. spells. You call the neonatologist to report
Do not leave, delay, or omit exchange of change in status using SBAR. What do you
information. say?
Outcomes
Critical information is not lost during hand offs, S = Baby smith is having multiple apneas
patient transfer, or reporting change of status. and bradycardias about 1–2 every 5
Expectations remain clear. minutes. An increase in oxygen with
Conversations are framed and focus on patient vigorous stimulation is needed for
is maintained. recovery.
B = Baby is 34 weeks etc. (give a brief
Strategies/Tools medical history)
Use standardized communication such as the A = Lung sounds are diminished,etc. (give a
SBAR script, call-out, check-back as the summary of the most current assessment)
SBAR script, call-out, check-back R = I recommend that this baby be receives
S = Situation, B = Background, A = further evaluation.
Assessment, R = Recommendation
Use Call-outs to direct information at a specific Call-out is used during emergency situation
individual such as a code.
Use Check back to close the communication Check-back is useful in emergency situations
loop and ensure that the message got and and in confirming that instructions to
was understood by the intended receiver. parents are understood and
comprehended.

2010 National Quality Report showed improvement in in culture change and teamwork. Finally, the need
patient safety over the last 6 years, however, gaps in for comparative effectiveness research with cost-benefit
how medical errors, handoffs and patient care transi- analysis of safety practices and programs is critical.
35
tions are managed exist. A great need remains in un-
derstanding what contributes to such gaps and what CONCLUSION
the best strategies are to remove the barriers to safe The influence of work culture on patient safety can-
care. There is also the need to translate science and ex- not be underestimated. Many elements that constitute
isting evidence into practice. Future research needs to what we call work culture directly affect how health-
focus on implementing and evaluating new evidence- care professionals perform their jobs and how pa-
based interventions and practices that promote patient tient safety is perceived and achieved. Beliefs, norms,
safety and this includes improving workload under se- and attitudes exhibited by healthcare professionals are
vere nursing shortage, designing valid and reliable mea- expressed through the way in which team members
sures of safety and quality and sustaining improvements interact with one another and perform patient care.

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Table 4. Practice recommendations

• Strive for excellence in clinical practice and team practice (For example, stay abreast of new treatments and practices,
uphold professional values, know your scope of practice and when faced with complex situations seek multiple
perspectives).
• Make patient safety a priority.
• Be aware of human fallibility and of system failure. Even the best of us are vulnerable to commit errors.
• Be a change agent and challenge the status quo.
• Be vigilant to your unit’s safety needs and take an active role in addressing those needs.
• Identify stakeholders at your organization or unit who have the best interest of the patient at heart and develop a
sense of urgency to change unsafe workplace practices.
• Use face-to-face communication when possible & ask questions.
• Document and report any deviation in patient care “An incident is usually a precursor for an accident.” Turn incidents
into learning opportunities. (Evaluate what happened, review the event, and bring attention to the issue so that
corrective actions can be taken).
• Practice patient-centered-care, partner with the families. Make necessary information available. Listen to their
concerns and respect their desires.
• Avoid shortcuts and workarounds to save time when using equipment, procedures, or workload. For example when
using a medication bar code, avoid scanning medications without checking the 5 rights or scanning medication bar
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