Culture of safety i.e. how we do things
in our unit Shared vision required
Safety is considered important Clear guidelines in place on safe practices for all staff
Expected pattern of behavior Good teamwork Leadership in safety Environment geared to safe practices Fig. 66.1 Requirements of a culture of safety in the neonatal unit.
(Adapted from J. Horbar, Vermont–Oxford Network.)
Medication errors
Why?
• Prescription errors occur as there is a wide range of dosage – varies 10‐fold if baby weighs 0.5 kg or 5 kg (unlike adults, where there is usually a standard dose).
• Dilutions often needed – common source of error.
• Use of potentially dangerous drugs – insulin, inotropes, aminoglycosides, digoxin, narcotics, heparin.
Prevention
• Staff training, utilising a pediatric pharmacist.
• Clear formulary.
• Minimize range of drugs used.
• Computer‐assisted guidance on dosage and dilutions.
• Avoid abbreviations, e.g. micrograms, not µg.
• Use limited number of standard dilutions, drawn up in pharmacy where possible.
• Clear differentiation between vials, e.g. by color.
• Checking by two trained professionals (but do not rely on this).
• Remove undiluted dangerous drugs, e.g. high concentration KCl.
• Use pre-programmed infusion pumps.
• Pay special attention to potentially dangerous drugs.
Fig. 66.2 Extravasation injury.
Fig. 66.3 Scarring from extravasation injury.
Critical incidents 155
What to do if extensive extravasation
• Aspirate cannula.
• Flush affected area with saline via several skin punctures. Some cen- ters inject hyaluronidase into extravasation site. Elevate affected limb.
• Consult plastic surgeons if concern about long‐term scarring.
Excessive fluid volume infused Cause
• Incorrect settings on pump.
• Malfunction of pump.
Prevention
• Electronic ‘guard-rails’ built into pumps (max and minimum rate based on infusion).
• Check and monitor infusion.
Giving wrong breast milk to wrong patient Cause
• Similar patient names.
• Poor labeling.
• Multiple milk containers kept in same fridge.
• Inadequate checking procedures.
Prevention
• Clear labeling.
• Double‐checking.
• Warning mechanism (name alert tags) for staff if babies have similar names.
• Electronic milk storage and dispensing systems.
What to do if occurs
• Inform parents.
• Test donor mother for blood‐borne viruses.
Complications of umbilical arterial catheters (UAC)
Incorrect vessel
• Inserted into umbilical vein instead of artery.
Prevention
• Check for presence of arterial pulsation to confirm in artery and arterial waveform on monitor.
• Check position on abdominal X‐ray (Fig. 66.4).
This is important – if in umbilical vein by mistake, excessively high oxygen could be given, which could damage eyes (retinop- athy of prematurity, ROP) if preterm.
Thrombosis/emboli/vasoconstriction
Consequences
• Occlusion of the artery causes mottling of skin, loss of pulses, cool limb and cyanosis in one or both legs. May result in gangrene/
amputation of limb.
• Emboli may affect distant organs.
Prevention
• Regular observation. If skin becomes discolored, reposition or remove catheter.
• Position catheter either high at T6–10 or low at L3–4 to avoid catheter tip near renal vessels to reduce risk of renal artery throm- bosis (hematuria, renal failure, hypertension).
• Flush catheter gently, heparin infusion.
• Ensure infant’s intravascular volume is adequate.
Blood loss from arterial catheters Cause
• Disconnection of catheter.
Prevention
• Clear labeling that catheter is arterial.
• Connections screwed together.
• Pressure‐sensitive alarm.
UAC in correct position
UVC in portal vein Incorrect position – must be withdrawn
Fig. 66.4 X‐ray showing umbilical arterial and venous catheters. Catheter in umbilical artery (red line) – initial course caudally towards groin, then cranially up middle of spine. Catheter in umbilical vein (blue line) – cranial course to right of spine. This catheter is in the portal vein, a potentially dangerous position, and must be withdrawn. In addition, overlapping catheters, as shown here, can easily lead to misinterpretation.
Ischemic damage from peripheral artery catheters
Cause
• Small size of vessel.
• Inadequate collateral supply.
Prevention
• Choose suitable artery:
• use radial artery only if ulnar artery shown to be patent (Fig. 66.5) (see Chapter 76 for Allen test).
• avoid superficial temporal artery as can cause ischemia of parietal lobe.
• avoid brachial artery as end artery and occlusion may result in loss of distal limb, and median nerve may be damaged.
• Only use for sampling, not injecting.
• Remove if any significant blanching, other than transient.
Portal vein thrombosis from umbilical venous catheters
Cause
• Catheter in portal vein causing portal vein thrombosis.
Prevention
• Check on X‐ray that catheter is in the inferior vena cava and not the portal vein (Fig. 66.4).
Extravasation of parenteral nutrition (PN) from central venous lines
Cause
• Catheters may migrate and PN may be infused into:
– the tissues, causing swelling and inflammation – the lungs, causing pleural effusion
– the pericardium, causing pericardial effusion and tamponade – the liver, causing hepatitis.
Prevention
• Check catheter tip is in the inferior or superior vena cava, not the right atrium or portal vein.
Burns and scalds Cause
• Overheating of humidifier in CPAP/ventilator circuit.
• Disconnection of temperature probe or malfunctioning of radiant warmer (Fig. 66.6).
• Failure to move transcutaneous O2/CO2 probes regularly.
Prevention
• Temperature alarms.
Scarring of skin Cause
• Poorly keratinized skin prone to long‐term scarring, especially if black ethnicity (keloid formation).
Prevention
• Minimize skin damage:
– care with adhesive tape, regularly reposition probes and avoid undue pressure from attachments for tracheal tubes, nasal CPAP, etc.
– if transcutaneous O2/CO2 electrodes used, rotate to different skin sites regularly
– procedures, e.g. chest tube for pneumothorax, avoid breast-bud area (Fig. 66.7).
Nasal damage from tracheal tube Cause
• Dilatation of nostril or damage to the nasal septum by tube.
Fig. 66.5 Ischemic damage from radial artery catheter.
Fig. 66.6 Scalding of skin from excessive heat from radiant warmer after dislodging of skin temperature probe. It resolved within a few hours.
Critical incidents 157
Prevention
• Avoid excessively large tracheal tubes.
• Avoid leaving in situ for long periods.
• Fix tube securely to prevent leverage.
Nasal damage from nasal CPAP Cause
• Pressure on nostrils or nasal septum.
Prevention
• Correct positioning, size and fixing of nasal prongs, avoiding excessive pressure on the nostrils or nose, regular repositioning and monitoring.
• Consider high flow nasal oxygen therapy as causes less nasal trauma.
Tracheal stenosis Cause
• Damage to subglottic area from tracheal tube (Fig. 66.8).
Prevention
• Avoid excessively large tubes.
• Minimize time left in place.
• Secure to prevent tube movement and irritation.
Infection Cause
• Nosocomial infection – inadequate hand-hygiene.
• Catheter related – at insertion or subsequently, e.g. breaking of long line and dressing.
• Procedures – infection where skin denuded from monitor probes or tape.
Prevention
• Meticulous hand hygiene.
• Sterile insertion.
• Minimize interference of lines.
• Remove lines as soon as possible.
• Care bundles of procedures to minimize infection shown to reduce central line-associated bloodstream infections (CLABSIs).
Aspiration pneumonia from misplaced gavage (nasogastric) feeding tubes Cause
• Tube inserted into trachea instead of stomach.
Prevention
• Check correct position with pH indicator paper to confirm gastric aspirate is acidic (pH < 5.5).
• If in doubt, X-ray to confirm below the diaphragm and in the stomach to the left of mid-line.
Fig. 66.7 Scarring from chest tubes. Fig. 66.8 Tracheal stenosis following prolonged mechanical ventilation.
The narrowed trachea is shown with an arrow.
Neonatology at a Glance, Third Edition. Edited by Tom Lissauer, Avroy A. Fanaroff, Lawrence Miall and Jonathan Fanaroff.
© 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd.
What is evidence‐based medicine (EBM)?
It is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.
Steps in the practice of evidence‐based medicine
See Fig. 67.1.