A Neonatal Intensive Care Unit's Experience with Implementing an In-Situ Simulation and Debriefing Patient Safety Program in the Setting of a Quality Improvement Collaborative.
Mary Eckels, Terry Zeilinger, Henry C Lee, Janine Bergin, Louis P Halamek, Nicole Yamada, Janene Fuerch, Ritu Chitkara, Jenny Quinn
Author Information
Mary Eckels: Maternal Newborn Services, St. Jude Medical Center, Fullerton, CA 92835, USA.
Terry Zeilinger: Maternal Newborn Services, St. Jude Medical Center, Fullerton, CA 92835, USA.
Henry C Lee: Neonatal Intensive Care Unit, Lucile Packard Children's Hospital, Stanford, CA 94305, USA. ORCID
Janine Bergin: California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA 94305, USA.
Louis P Halamek: Neonatal Intensive Care Unit, Lucile Packard Children's Hospital, Stanford, CA 94305, USA.
Nicole Yamada: Neonatal Intensive Care Unit, Lucile Packard Children's Hospital, Stanford, CA 94305, USA. ORCID
Janene Fuerch: Neonatal Intensive Care Unit, Lucile Packard Children's Hospital, Stanford, CA 94305, USA.
Ritu Chitkara: Neonatal Intensive Care Unit, Lucile Packard Children's Hospital, Stanford, CA 94305, USA.
Jenny Quinn: California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA 94305, USA.
Extensive neonatal resuscitation is a high acuity, low-frequency event accounting for approximately 1% of births. Neonatal resuscitation requires an interprofessional healthcare team to communicate and carry out tasks efficiently and effectively in a high adrenaline state. Implementing a neonatal patient safety simulation and debriefing program can help teams improve the behavioral, cognitive, and technical skills necessary to reduce morbidity and mortality. In , a 15-month quality improvement (QI) project, the Center for Advanced Pediatric and Perinatal Education (CAPE) and California Perinatal Quality Care Collaborative (CPQCC) provided outreach and training on neonatal simulation and debriefing fundamentals to individual teams, including community hospital settings, and assisted in implementing a sustainable program at each site. The primary Aim was to conduct two simulations a month, with a goal of 80% neonatal intensive care unit (NICU) staff participation in two simulations during the implementation phase. While the primary Aim was not achieved, in-situ simulations led to the identification of latent safety threats and improvement in system processes. This paper describes one unit's QI collaborative experience implementing an in-situ neonatal simulation and debriefing program.
