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Real-time safety audits can detect a broad range of errors in neonatal intensive care units

Real-time safety audits performed during routine hospital neonatal intensive care unit (NICU) work can quickly detect a broad range of medical errors, concludes a study supported in part by the Agency for Healthcare Research and Quality (HS11583). The audit system, implemented in a 20-bed NICU, detected significant safety problems promptly (usually at the patient's bedside) leading to rapid changes in policy and practice.

Researchers at the Vermont Center for Patient Safety in Neonatal Intensive Care developed a 36-item patient safety checklist. The checklist included errors associated with delays in care, equipment failure, diagnostic laboratory and radiological tests, information transfer, and non-compliance with hospital policy. A research nurse used the checklist to perform safety audits during and after morning work rounds three times a week. Clinical personnel were involved in the design and implementation of the study where they helped detect gaps in performance. This limited the burden of data collection and helped clinical personnel accept and support the safety audits.

Safety audits detected 338 errors during the 5-week study period such as unlabeled medication at the patient's bedside, missing or inappropriately placed identification bands, improper alarm settings on pulse oximeters (which measure blood oxygen saturation), ineffective communication, and delays in appropriate care. Overall, 17 errors were associated with laboratory or radiology studies, 9 with ineffective communication or delays in patient care, 8 with medical devices, 1 with pain management, 260 with deviation from ICU or hospital policy, and 43 with deviation from known safe practices. Errors were usually detected at the patient's bedside, which allowed immediate notification of clinical staff.

See "Real time patient safety audits: Improving safety every day," by Robert Ursprung, M.D., James E. Gray, M.D., M.S., William H. Edwards, M.D., and others in Quality and Safety in Health Care 14, pp. 284-289, 2005, which can be obtained online from

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