The Impact of Non-Routine Events on Neonatal Safety

Neonates are highly vulnerable to iatrogenic events due to their size, fragility, and severe sensitivity to environmental stressors. Patient safety research in neonatal intensive care units (NICU) has shown that these attributes increase care complexity and reduce the capacity of the neonates to endure even small care deviations. As a result, neonates experience adverse events at rates as high as 8 times of those reported for hospitalized adults. Adverse events are estimated to occur at a rate of 74 events per every 100 NICU patients (0-11 Adverse Event(AE)/patient), with a third being severe events. The vulnerabilities of neonates are most exposed in the perioperative environment, in which little patient safety research has been conducted. In addition to the prevailing risks to all surgical patients (e.g., misidentification, positioning errors, wrong site or side, retained foreign bodies, etc.), neonates are at increased risk to handover (e.g., NICU nurse to Operating Room team), transport (e.g., monitoring), and intraoperative events (e.g., weight-based dosing, temperature control, etc.).

The objective of this multi-site study is to improve neonatal safety by applying a novel event discovery methodology to determine the etiology of system failures in the perioperative environment. The investigators will use the construct of the non-routine event (NRE) to more efficiently capture dysfunctional clinical microsystem attributes and potentially dangerous conditions. A NRE is defined as any event that is perceived by care providers or skilled observers as a deviation from optimal care based on the clinical situation. NREs encompass a substantially larger class of events than conventional patient safety metrics, including sentinel events, medical errors, or "near misses". In prior studies, minimizing the number of deviations from standard care, minor problems, and disruptions during a case has been shown to result in smoother, safer, and shorter surgeries. Moreover, in preliminary studies by members of the research team, intraoperative NREs appeared to be associated with 30-day surgical mortality and morbidity. The Investigators propose a comprehensive 4-year study of neonatal patient safety in the perioperative environment to produce the knowledge base required to inform high-impact intervention studies and guide rapid cycle quality improvement.

The study's Aims are to:

1a) Determine the prevalence and characteristics of NREs during the perioperative care of neonates;

1b) Delineate the relationship(s) between NREs, contributory factors, and surgical mortality and major morbidity during neonatal perioperative care;

1. Perform a comparative analysis of prospective NRE data collection with conventional event reporting methodologies within the same clinical environment; and
2. Collaborate with Primary Children's Hospital (PCH) in Salt Lake City, UT to conduct practical pilot testing of tools and measures refined in Aims 1-3.

The investigators anticipate that knowledge gained from a neonatal safety model developed from data collected prospectively at three children's hospitals and tested within PCH will guide future intervention studies.

A product of the project will be a patient safety registry for surgical neonates. The registry will include a sample of approximately 500 neonatal patients receiving first-time non-cardiac surgical intervention at Monroe Carell Jr. Children's Hospital at Vanderbilt. Neonates who receive NICU care both pre- and post-operatively will be eligible for this study. The registry will include the following data elements: NRE data captured prospectively in the NICU pre-operatively, intraoperatively, and post-operatively, respectively, by trained observers; contributory factors including factors related to patients, clinicians, equipment, logistics, and work environment; and 30-day National Surgical Quality Improvement Project-Pediatric (NSQIP-P) morbidity and mortality outcomes. NRE severity will be categorized and coded as:

1. Serious Safety Event (SSE);
2. Precursor Safety Event (PSE), or
3. Near Miss Safety Event (NME) based on the Safety Event Classification (SEC) system taxonomy.

Surgical morbidity will be categorized using the NSQIP-P taxonomy and classified as Serious (Moderate Temporary Harm to Severe Permanent Harm) or Not Serious (No Harm to Minimal Permanent Harm) using the SEC definitions of levels of harm.