• Thermoregulation monitoring following delivery

• The use of servo mode on our extreme preterm population

• Early breast milk administration within 6 hours

• Supporting mothers to express within 2 hours of delivery

Clare Atkinson - Clinical Governance Lead NICU Ext 5202

Katie Wood - Clinical Governance Lead NICU Ext 5202

Cecilia Perez Fernandez - Consultant Governance Lead

Hannah Wood - Consultant Quality Improvement Lead

Sarah Ellis - Governance Matron Ext 5228

Dora Reeves

Jordan Chandler

Romarni King

Terri Field

Lucy Green - Consultant Mortality Lead

Matt Cawsey - Mortality Consultant

Gill Preston - Mortality Consultant

Hannah Wood - Mortality Consultant

Manobi Borooah - Mortality Consultant

A risk register is a tool used to document and manage potential risks on the NICU, helping to identify, analyze and mitigate these risks. It is an integral part of risk management and centralizes risk information and helps to assist with decision making and ensures accountability.

All datix's relating to any risks on the risk register will be linked to the risk to gather evidence to support the need for change in practice or to further manage the risk.

• A risk to the provision of safe care due to insufficient number of senior medical workforce.

• If there is limited neonatal specific care at BCH then this could impact on neonatal outcomes.

• If NICU do not meet BAPM standards (with regards to QIS nurses) then we will have an unbalanced skill mix.

• If we do not improve thermoregulation for babies less than 34 weeks then there is an increased risk of mortality.

• If there us not an adequate inpatient non-emergency transport service, then patient care is compromised.

• If procurement processes and controls are not amended in NICU there is a financial risk to the trust.

• If we do not improve the rates of NEC for babies less than 32 weeks then we might remain outlier for this measure.

• Inability to perform GI contrast studies at BW resulting in delayed diagnosis, treatment and poor patient and family journey.

• If the main corridor floor on the Neonatal unit is not replaced it may continue to erode causing structural damage

• If the decontamination room is not upgraded then there is a risk to further infections on the NICU.

• If we do not reduce rates of blood stream infection in babies less than 32 weeks then there is an increased risk of mortality

• If the location of TC remains then there is an increased risk in keeping the staff and patients safe.

• If there is no on-site radiology cover out of hours leading to delayed imaging, diagnosis and treatment.

• If the floor is not repaired then there is an increased risk of infection outbreak on the neonatal ward.

• Birth in the right place

• Antenatal Steroids

• Magnesium sulphate

• Intrapartum antibiotics

• Optimal Cord Management

• Thermoregulation

• Volume targeted ventilation

• Caffeine

• Early breast milk

• Probiotics

• Prophylactic hydrocortisone

If you have any issues with EPIC EPR, please seek support with our Super Users in the first instance. If they can not help, please raise a IT ticket and let the matrons know.

How to report:

• Clean the item

• Place smaller items on middle desk, large items place in isolation area near the resuscitaire

• Call medical engineering on 8555 to report. During working hours, they will collect immediately. Out of hours, leave a voicemail and they will collect during working hours the following day. Please state what the equipment is, it's asset number (on the yellow label), what is wrong with it, and where it is located.

• Leave a note on the equipment stating that it is broken and date it has been reported.

There is no home for broken equipment. Do not leave in ladybird or incubator room. This is to prevent non-reported equipment from accumulating and resulting in patient safety events.

Delay/Failure in Care or Treatment: Episode of hypoglycaemia was not escalated.  Tongue tie not detected on NIPE.  Delayed diagnosis of imperforate anus.

Medications:  Gentamicin level taken post administration instead of pre-dose.  SMOF lipid running instead of intralipid.

Patient Tests and Scan Issues:  Baby discharged at 6 days with no newborn screening completed.  No day 0 sample taken on baby who needed a blood transfusion.

Pressure Injury:  High flow prongs left indent in baby’s skin.  Blood pressure cuff left indentation.

Clinical Equipment: Cooling wraps leaking.  All 3 nitric machines in use.

Cardiac/Respiratory arrest, ALTE:  4 deaths.

Delay/Failure in Care or Treatment: Bilirubin level not plotted therefore treatment not started.

Feeding issues: Wrong breast milk given to baby by student nurse.  Baby fed the wrong formula.

Access to Services: St Johns ambulance not available for transfer.

Medications and other administered products:  Vial of IV morphine found to be unopened but empty. 

Clinical Equipment: Cooling wrap leaking.

Delay/Failure in Care or Treatment: KP score entered incorrectly which led to delay in giving antibiotics to baby.

Majority of the time this is a result of a delayed transition and has quickly resolved. Learning from ATAIN reviews suggests commencing on low flow oxygen and escalating upwards as required.

Access to Services: MRI booked but St Johns have no availability to transport. Suspension of the 27-week pathway.  No PICU capacity so surgical babies transferred out of region.

Clinical Equipment: Limited stock of in-house incubator circuits.  Premicath snapped at the hub, Premicath leaking near the hub.  No size 6 inline suction catheters.

Delay/Failure in Care or Treatment: Day 28 repeat newborn screening not completed on discharge. NIPE not completed prior to transfer to TC. 

Cardiac/ Respiratory Arrest, ALTE: Sadly 5 babies passed away.

Access to Services: MRI booked but St Johns have no availability to transport. Baby noted to not have a follow appointment booked. Datix to record over capacity.

Other Clinical Incident: Preterm delivery at QE hospital. X3 datix for St John’s ambulance not available for MRI bookings.

Delay/Failure in Care or Treatment: Baby discharged without repeat newborn bloodsport screening for SCID. Bloodspot screening taken but not sent. Baby discharged from postnatal without NIPE.   

Cardiac/ Respiratory Arrest, ALTE: Sadly 2 babies passed away. Baby required chest compressions following PICC line extravasation.

Clinical Equipment: CVL leaking.  ECG machine was not working.

Access to Services: No St Johns ambulances available for MRI scan x3.

Documentation/Information Governance:  Triplets born but unable to admit until 3 hours post birth.   Outpatient ROP screening booked incorrectly.

Patient Tests and Scan issues: NIPE not completed.  SBR taken in community baby admitted to TC bilirubin below the treatment line.