22 A neonatal unit with a memory

• Published in: Archives of disease in childhood 2023-07, Vol.108 (Suppl 2), p.A131-A132
• Main Authors: Parmenter, Kate, Miall, Lawrence, Broadwell, Emily
• Format: Article
• Language: English
• Subjects: Human factors; Intensive care; Learning; Neonatal care; Neonates; Newborn babies; Pediatrics; Risk reduction
• ISSN: 0003-9888; 1468-2044
• DOI: 10.1136/archdischild-2023-rcpch.218

Objectives‘An organisation with a memory’ was published by the then chief medical officer, Dr Liam Donaldson in 2000.1 It recognised that errors tend to recur in the NHS. Harm occurring in the neonatal period can have lifelong consequences. Research has shown errors can occur in up to 10% of all admissions.2The aim of this report was not to highlight personal errors, but to share the learning so that new staff, as well as existing members of the wider MDT, are equipped with the knowledge and benefits arising from the organisational learning that has occurred.MethodsWe reviewed 5 years’ worth of critical incident reports and came up with a shortlist of 11 themes. We developed a 1 page per incident learning burst for each and grouped them together as a PDF to share key learning from each case, examining both the good and bad.We kept an oversite about how errors could be categorised such as some incidents were due to ‘human error’ and thus inherently difficult to predict. There are ‘human factors’ relating to the systems we work in, and some are due to latent, built in risks within the system.We aim to show that investigating such incidents, with transparent dissemination of the learning thereafter, can help make systematic changes, thus reducing the risk of them recurring again.ResultsOnce we had compiled our ‘Neonatal Unit with a memory’, we sent out a survey to all members of the MDT and received a response from 39 staff members. 84.6% had read the document with 75% indicating that they thought this work would prevent similar mistakes from happening again, 27.8% thought such work had the benefit to potentially positively effect ward risk and safety culture. No respondents thought this document was unwarranted.ConclusionNeonatology is inherently a high-risk area of medical and nursing practice. Neonatology is also about teamwork, we help our patients by helping each other; by carefully checking when things don’t seem right, by speaking up when we have concerns, by not interrupting dose calculations, by following safety protocols and guidelines and by asking for help when we are not sure.We must also look after each other when things go wrong. None of us come to work to make mistakes or to cause harm, but sadly few of us will get through our careers without making a mistake that affects a patient.ReferencesDonaldson L. Clin Med (Lond). 2002 Sep-Oct;2(5):452–7. doi: 10.7861/clinmedicine.2-5-452.PMID: 12448595Iacobucci G. NHS in 2017:Keeping pace with society.