1. Verklan, M. Terese PhD, CCNS, RNC, FAAN

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The neonatal intensive care unit (NICU) is an incredibly complex system composed of more and more subsystems necessary to care for the vulnerable preterm and critically ill neonates. Keeping patient safety at an optimal level requires that a wide range of healthcare professionals from numerous subspecialties must coordinate flawlessly to protect the high-risk neonate from harm. Because nurses have a continuous presence at the bedside, they are essential in protecting their patients from harm. There is conflicting research regarding the effects of staffing ratios, level of education, clinical expertise, patient safety knowledge, and the overall organizational culture related to patient safety.1-4 Since the publicity from the infamous Colorado malpractice case where a neonate died from an overdose of penicillin, it was realized that interactions between humans and systems influence patient safety and outcomes using the "Swiss Cheese" model. In addition, the concepts of quality care and patient safety have developed programs and structures to improve outcomes, although the relationship between the two is not well understood.5


The philosophy supporting the science of human factors is that patient safety can be optimized by improving systems and procedures that work best with nurses working within the NICU, rather than using discipline and shame to train mistakes out of them.6 To decrease errors, equipment, clinical tasks, products, the NICU and the organization of which the NICU is a subsystem of are considered, designed, and evaluated within the framework of the abilities, limitations, and needs of the nurses. Rather than the "blame and retrain" and "Swiss Cheese" approaches, the "Safety II approach" is used to understand how things should go right, instead of preventing actions from going wrong.6 The impetus to improve patient safety was the publication by the Institute of Medicine "To Err Is Human: Building a Safer Health System."7 Since then all hospital settings strove to set goals related to patient safety to improve outcomes and quality of care. Areas using human factors thinking include teamwork in the NICU, improved communication during resuscitations, and optimizing transition from the operating room to the NICU, especially for cardiothoracic surgical procedures.6


Quality of care and patient safety are associated concepts and may be considered synonymous, although distinct elements may determine safety and quality individually. Depending on the NICU or organizational framework used to address issues related to safety and quality, safety may be viewed as minimizing/negating errors that impact the individual neonate and family and quality is thought of as enhancing outcomes for the population of neonates. There often is a Chief Safety Officer and a Chief Quality Officer responsible for separate activities related to their respective areas. Nevertheless, what is important is that both areas understand how to achieve safe and quality care even if different strategies are used to attain the goals. Quality improvement initiatives will use methodologies to determine what needs to be accomplished and what changes are specifically needed to improve care/safety and evaluate that a change was an improvement. The Framework for Safe, Reliable and Effective Care is a broad model for quality and safety at the organizational level.8 There are 9 components related to safety and quality organized into 2 categories. The culture category includes accountability, teamwork and communication, negotiation, and psychological safety. The learning system includes leadership, transparency, reliability, continuous learning, and improvement and measurement. While leadership is housed in the learning system, it is also a part of the culture domain. At the heart of framework is engagement of the neonate and family.8


The NICU is a multifaceted sociotechnical system with components that include people, technology, processes, organization, and environment. The improvement in patient safety and quality care demands that we continuously learn from positive and negative experiences. There are a number of systems approaches in use across the country, such as Collaborative Care Models and Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), to address safety and quality improvements. Because patient care in the NICU demands the expertise of multiple specialties and subspecialties, it is beneficial to engage in team-based assessment and shared decision-making to ensure the safe delivery of quality care.


-M. Terese Verklan, PhD, CCNS, RNC, FAAN


Professor and Neonatal Clinical Nurse Specialist


University of Texas Medical Branch


School of Nursing


Graduate School of Biomedical Sciences


Galveston, Texas




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