Neonatal intensive care, patient safety and quality improvement: What? When? Where? Who? And How?

A guest article by Dr Cynthia van der Starre

Ever since the release of the landmark report “To Err is Human” by the Institute of Medicine in November 1999, the science behind improving patient safety and quality of care has been increasing steadily. Not only “classical” medical research has contributed to evidence-based ways for quality improvement, but also the influence of a growing number of methodological, social, psychological, anthropological, economical and other studies has impacted our way of thinking about improving processes. The wide variety of applied research topics is an indicator of how healthcare systems provide multiple starting points for implementing improvements. This also implies that for improvements across a healthcare sub-discipline such as neonatology, a wide variety of stakeholders needs to be involved.

For most NICUs (neonatal intensive care units) the first step towards safer care involved setting up a blame-free incident reporting system. This not only provided insight into how care was delivered and what opportunities existed to prevent errors from happening but also promoted having open discussions on what had happened and why without blaming and shaming the individual involved in the incidents. Thereby, the importance of psychological security as a requirement to allow improvement work to be successful was demonstrated. The system’s approach in analyzing incidents, near-misses and never-events as resulted in numerous initiatives and improvements across a wide range of topics, such as prevention of medication errors, increasing hand hygiene, safer use of equipment, etc.

Recently, the approach of addressing the system’s issues by uncovering what went wrong and why has been labelled safety I. However, by only focusing on the errors, lapses and omissions, there is the chance that a large proportion of work done in the NICUs, namely the many things that go right, is being ignored as opportunities for learning and improving! This new approach, labelled safety II, encompasses looking at both, the tasks that what went wrong, and those that what went (remarkably) well. This holistic approach aims to expose the contributing factors to improving healthcare processes.

Another steadily increasing influence in quality and safety improvement has been the ongoing development of patient and family involvement in the care provided for NICU patients. We have seen numerous initiatives aimed at increasing shared decision making, showing that patient and family centred care is evolving beyond creating rooming-in or kangaroo-care facilities. Parents are increasingly regarded to be team members, not only in the team providing care for their infant(s) but also as team members of the broader team such as an entire NICU. For instance, parents are on advisory boards and are co-designing care pathways, research and education. This creates an opportunity to broaden the involvement of families to include their perspective and input in improving patient safety and quality of care.

For further information on “Patient Safety in Pediatrics a developing discipline” and the safety  first  project,  please click here

©Cynthia van der Starre

Dr  Cynthia van der Starre is a Pediatrician-neonatologist at the Erasmus MC Sophia Children’s Hospital in Rotterdam, The Netherlands.
She is specialized in patient safety and quality of care.