Challenge 7

Neonatal Safety

Neonatal safety addresses patient safety in the context of a vulnerable group of patients, newborns or neonates. Improving neonatal care and safety reduces harm, prevents adverse events from taking place, and optimizes the care of newborns in the healthcare setting. PSMF is currently focused on two critical and common neonatal safety challenges: Suboptimal Neonatal Oxygen Targeting and Failure to Detect Critical Congenital Heart Disease (CCHD).

Each Actionable Patient Safety Solutions (APSS) includes an Executive Summary Checklist, Performance Gap, Leadership Plan, Practice Plan, Technology Plan and Metrics. Please click Download below to view the full document. A preview of the Executive Summary is offered below.

Sub-Challenges

Statistics

At least 300 infants with an unrecognized CCHD are discharged each year from newborn nurseries in the United States.1
1.

Aamir T, Kruse L, Ezeakudo O. Delayed diagnosis of critical congenital cardiovascular malformations (CCVM) and pulse oximetry screening of newborns. Acta Paediatr. 2007;96:1146-1149

Critical congenital heart disease is estimated to affect one out of every 48,000 babies born each year in the U.S.2
Studies show that newborns treated with higher level of oxygen had more cognitive disabilities than those treated with lower oxygen.3
3.

Sun SC. Relation of target SpO2 levels and clinical outcome in ELBW infants on supplemental oxygen. Pediatr Res (2002) 51:A350.

Prevention or minimization of harm through adherence to evidence-based practice guidelines is the best defense against patient harm and malpractice claims.4
4.

Perinatal Safety Intervention Program (PSIP): Design and Development: AHRQ’s 2012 Annual Conference Slide Presentation. December 2012. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/news/events/conference/2012/track_a/106_hendrich_kamerow/kamerow.html

Birth-associated adverse outcomes result in 2-10% or approximately 80-400,000 cases annually, half of which are preventable.5
5.

Perinatal Safety Intervention Program (PSIP): Design and Development: AHRQ’s 2012 Annual Conference Slide Presentation. December 2012. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/news/events/conference/2012/track_a/106_hendrich_kamerow/kamerow.html

30-40% of birth-associated adverse outcomes or “near misses” may be preventable through changes in patient, health care provider, and system factors.6
6.

Perinatal Safety Intervention Program (PSIP): Design and Development: AHRQ’s 2012 Annual Conference Slide Presentation. December 2012. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/news/events/conference/2012/track_a/106_hendrich_kamerow/kamerow.html