A neonatal intensive care unit at Cincinnati Children's Hospital Medical Center made 19 improvements after identifying latent safety threats — errors in design, organization, training or maintenance that may contribute to medical errors and impact patient safety, according to a study in The Joint Commission Journal on Quality and Patient Safety.
Multidisciplinary teams of NICU providers participated in laboratory and in situ (in a Level III academic NICU) simulations from August 2009 to March 2011 and identified latent safety threats in debriefings following each scenario. In the simulation laboratory the teams identified 70 latent safety threats, and in situ the teams identified 29 latent safety threats, 22 of which were new threats not previously identified in the laboratory, according to the study.
The 99 total latent safety threats were reported to NICU leadership, which subsequently made 19 improvements. The improvements were categorized into three areas:
• Within the NICU. For example, nursing education competency was created and executed for adenosine delivery.
• Delivery room process. For example, leaders created a recording sheet for documentation of care and added it to the delivery cart.
• Within the hospital. For example, the hospital CPR committee revised labeling for intraosseous access supplies in code carts.
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Multidisciplinary teams of NICU providers participated in laboratory and in situ (in a Level III academic NICU) simulations from August 2009 to March 2011 and identified latent safety threats in debriefings following each scenario. In the simulation laboratory the teams identified 70 latent safety threats, and in situ the teams identified 29 latent safety threats, 22 of which were new threats not previously identified in the laboratory, according to the study.
The 99 total latent safety threats were reported to NICU leadership, which subsequently made 19 improvements. The improvements were categorized into three areas:
• Within the NICU. For example, nursing education competency was created and executed for adenosine delivery.
• Delivery room process. For example, leaders created a recording sheet for documentation of care and added it to the delivery cart.
• Within the hospital. For example, the hospital CPR committee revised labeling for intraosseous access supplies in code carts.
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