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The aim of this study in the journal Pediatrics was to explore the impact of rudeness on the performance of medical teams. Twenty-four NICU teams participated in a training simulation involving a preterm infant whose condition acutely deteriorated due to necrotizing enterocolitis. Participants were informed that a foreign expert on team reflexivity in medicine would observe them. Teams were randomly assigned to either exposure to rudeness (in which the expert’s comments included mildly rude statements completely unrelated to the teams’ performance) or control (neutral comments). The videotaped simulation sessions were evaluated by three independent judges (blinded to team exposure) who used structured questionnaires to assess team performance, information-sharing and help-seeking. The authors concluded that rudeness had adverse consequences on the diagnostic and procedural performance of NICU team members. Information-sharing mediated the adverse effect of rudeness on diagnostic performance, and help-seeking mediated the effect of rudeness on procedural performance.

This paper, published by the National Bureau of Economic Research (NBER) aimed to explore how parental wealth and race affect maternal and infant health outcomes in California. The authors used administrative data that combines the California birth records, hospitalisations and death records with parental income from Internal Revenue Service tax records and the Longitudinal Employer-Household Dynamics file to provide new evidence on economic inequality in infant and maternal health. The paper also used birth outcomes and infant mortality rates in Sweden as a benchmark, finding that infant and maternal health is worse in California than in Sweden for most outcomes throughout the entire income distribution. Key findings Babies born to the richest 20% of families are the least healthy. They are more likely to be born premature and at a low birth weight, two key risk factors for medical complications early in life. This is because their mothers are more likely to be older and to have twins (which are more common with the use of fertility treatments). However, even with those early risk factors, these babies are the most likely to survive both their first month and first year of life. Rich and poor mothers were equally likely to have high-risk pregnancies, but the poor mothers were three times as likely to die—even within the same hospitals. Maternal mortality rates were just as high among the highest-income Black women as among low-income white women. Infant mortality rates between the two groups were also similar. Babies born to the richest Black women (the top tenth of earners) tended to have more risk factors, including being born premature or underweight, than those born to the richest white mothers—and more than those born to the poorest white mothers.

Published in Acta Paediatrica, the parents of a baby who was born prematurely and died, share their experiences of the communication and choices given to them before the birth.

Infants born preterm or with complex congenital conditions are surviving to discharge in growing numbers and often require significant monitoring and coordination of care in the ambulatory setting. This toolkit, produced in the US, includes resources for hospitals that wish to improve safety when newborns transition home from their neonatal intensive care unit (NICU) by creating a Health Coach Program, tools for coaches, and information for parents and families of newborns who have spent time in the NICU.

Diagnostic uncertainty was relatively common in critically ill children admitted to the paediatric intensive care unit (PICU), an AHRQ-funded study in Critical Care Medicine concluded. Diagnostic uncertainty is the subjective perception of clinicians of their inability to provide an accurate explanation of a patient’s health problem. Researchers aimed to identify the frequency and factors associated with diagnostic uncertainty among critically ill children admitted to PICU. They reviewed the medical records of 882 patients admitted to one of four PICUs. Diagnostic uncertainty at admission was observed in 228 out of 882 patients. They also found a significant association between diagnostic uncertainty and diagnostic error. Researchers highlighted the need for more research and better strategies to address diagnostic uncertainty. 

A fire at the University Hospital of Leicester in 2023 led to the recommendation of a full evacuation of the tertiary neonatal unit. The incident was ultimately stood down—however, it highlighted the lack of inter-agency understanding regarding the difficulty and complexity of moving critically unwell and premature babies in the event of a major incident. In response, the Leicester Royal Infirmary and other agencies staged a simulation exercise to enable teams to prepare for possible future incidents. This HSJ article describes the simulation exercise and the lessons it revealed about managing neonatal unit evacuations during major incidents. It highlights key learnings around the two themes of communication and estates.

Pain and trauma experienced as a preterm baby in the NICU have been linked to lasting psychological injury, altered brain development and individuals' ability to regulate emotions later in life. In this blog, Vox's Science and Health Editor Brian Resnick looks at how scientists are investigating how to treat pain in babies who can’t tell you when it hurts.

This investigation by the Healthcare Safety Investigation Branch (HSIB) explored the detection and diagnosis of jaundice in newborn babies, in particular babies born prematurely (before 37 weeks of pregnancy). Specifically, it explored delayed diagnosis due to there being no obvious visual signs of jaundice apparent to clinical staff. Jaundice is a condition caused by too much bilirubin in a person’s blood. Bilirubin is a yellow substance produced when red blood cells are broken down. If left undiagnosed and untreated, high bilirubin levels in newborn babies can lead to significant harm. Newborn babies have a higher number of red blood cells in their blood which increases their risk of jaundice. Jaundice can cause yellowing of the skin and whites of the eyes; however, sometimes the visual signs of jaundice are not obvious, particularly for premature or newborn babies with brown or black skin. The reference event for this investigation was the case of baby Elliana, who was born at 32 weeks and 1 day via a forceps delivery and then transferred to the Trust’s special care baby unit (SCBU). Elliana was assessed on admission to the SCBU by staff as a clinically stable premature baby and a routine blood sample was taken from around two hours after her birth to establish a baseline. Analysis of the blood sample indicated bilirubin was present and so the level was measured. This result was uploaded onto the Trust’s computer system alongside the results of the blood tests that had been requested by the clinical team. The bilirubin result was seen by a SCBU member of staff who recognised that the level was high, indicating the possible need for treatment. However, this member of staff was then required to attend an emergency and the bilirubin result was not acted upon. Another blood sample was taken when Elliana was two days old and was uploaded to the Trust’s computer system. It is unclear if this bilirubin result was seen by staff; it was not documented in clinical records and was not acted upon. Over the next two days, Elliana continued to show no visible signs of jaundice that were detected by staff and she was documented to be developing well. When Elliana was five days old, a change in her skin colour was observed and visible signs of jaundice were detected. A further blood sample was taken which showed she had a high level of bilirubin in her blood and treatment was started accordingly. Elliana’s bilirubin levels returned to within acceptable levels over the next three days and she was subsequently discharged home. Findings The assessment of visual signs of jaundice in newborn babies is subjective and more challenging with babies who have black or brown skin. Stakeholders have differing opinions about the reliability of visual signs to detect jaundice in newborn babies. Some neonatal units have introduced safety measures to mitigate the risk of reliance on visual signs of jaundice. National guidance does not recommend routinely measuring bilirubin levels in babies who are not visibly jaundiced. National guidance for jaundice in newborn babies maybe more applicable to term babies (those born after 37 weeks of pregnancy) than those born prematurely. National guidance does not contain information on how to address the challenges of detecting jaundice in newborn babies with black or brown skin. Some universities providing education to NHS students on the detection of jaundice are seeking to ensure that teaching aids and literature represent the diversity of the population. Levels of bilirubin can vary according to the gestational age of a baby (how long the baby was in the womb). Laboratory staff do not calculate the gestational age of a baby and therefore whether their bilirubin level is within the expected range. Laboratory practice varies in terms of whether they set specific reference ranges for bilirubin in newborn babies; whether they have a defined threshold for communicating results to neonatal units; and whether the telephone alert limit (the level of bilirubin that triggers laboratory staff to report the result to clinical staff by telephone) reflects the thresholds in national guidance. Neonatal staff may be unaware that laboratories analyse blood samples to see if they are icteric (indicate jaundice). These staff will not know to look for a comment about this on blood test reports. Safety recommendations HSIB recommends that the National Institute for Health and Care Excellence reviews the available evidence and updates its guidance if appropriate, regarding: the reliability of visual signs to detect jaundice in newborn babies, particularly in babies with black and brown skin risk factors for jaundice identified by this investigation, including prematurity. HSIB recommends that the Royal College of Pathologists works with stakeholders to understand current practice and make any appropriate recommendations to promote the adoption of an icteric threshold at which a bilirubin test may be cascaded or reported. HSIB recommends that the Royal College of Pathologists works with stakeholders to understand current practice and make any appropriate recommendations on neonatal specific reference ranges for total bilirubin and thresholds for direct communication of these results to clinicians. Safety observations HSIB makes the following safety observations: It may be beneficial for regulators of pathology services to consider the findings of the investigation and amend their guidance if necessary. It may be beneficial to develop a national standardised Early Warning System track and trigger observation chart for use in neonatal unit settings.

This video from the Irish Health Services Executive (HSE) tells the story of Barry, a paediatric nurse who made a medication error when treating a critically ill baby. Barry describes how the incident and the management response to it affected his mental health and confidence over a long period of time. He also describes how he had to fight to ensure the family were told the full story of what had happened, and the positive relationship he developed with the baby's mother as a result. The baby received the treatment they needed and recovered well.

The purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) was to consider the management and care of preterm labour and birth of twins. Preterm birth—defined as babies born alive before the completion of 37 weeks of pregnancy—is one of the main causes of death, long-term conditions and disability in under-fives worldwide, and 60% of twin pregnancies result in premature birth. The reference event for this investigation was the case of Sarah, who was pregnant with twins and was overseen by an obstetrician during her pregnancy. Sarah was assessed as having a higher-risk pregnancy as she had had previous medical intervention on her cervix and was pregnant with twins. Shortly after having been discharged from a hospital with a specialist neonatal unit following suspected early labour, she went to her local maternity unit at 29+2 weeks with further episodes of abdominal tightening. Her labour did not progress as expected and a caesarean section was required to deliver the babies at 29+6 weeks. The twin girls were born well, but 23 days after their birth a scan revealed brain injury in both babies. The investigation identified several findings to explain the experience of the mother in the reference event, including the lack of scientific evidence or specific guidelines and the uncertainty associated with the clinical decision making in this scenario. This highlighted the need for further research into preterm labour as a recognised risk factor for twin pregnancies. As part of the investigation, HSIB identified that since 2019 a large volume of national work and research in the area of twin pregnancy and preterm birth has been undertaken. The investigation report sets out the work currently in progress and seeks to understand if it will address gaps in knowledge. HSIB was notified about potential patient safety issues by Sarah, who was concerned about the care she had received when her babies were delivered. The investigation used interviews, observations of the maternity unit and reviews of guidelines and organisational documents in order to understand the system-wide factors that contributed to Sarah’s experience and the decisions made by staff. The evidence suggested that the process of decision making in the context of Sarah’s care was relevant to this investigation, so the investigation has summarised the key factors that appear to have influenced the decision making associated with her care and the delivery of her babies Findings There are currently no proven treatments available to reduce the risk of preterm labour for twin pregnancies. There are gaps in scientific knowledge and challenges to completing research in the field of preterm labour and birth. This creates a challenge for the development of detailed guidelines to support clinical decision making. Guidelines and equipment recommended for managing and monitoring singleton (one baby) and full-term pregnancies are used to assist with clinical decision making about preterm twin pregnancies; some interventions within the guidelines are unproven for use in preterm twin pregnancies. Research and national improvement initiatives, such as the British Association of Perinatal Medicine perinatal optimisation care pathway and NHS England and NHS Improvement ‘Saving babies’ lives care bundle version two’ and the Maternity and Neonatal Safety Improvement Programme are improving the standardisation and implementation of evidence-based interventions. Intelligence from national data gathered by maternity units can support the learning on preterm labour and birth in twin pregnancies. Safety observations It may be beneficial if further research aimed to generate additional knowledge to predict and prevent preterm labour for twin pregnancies among different groups of women/pregnant people. It may be beneficial to increase awareness among the public and healthcare professionals of the limitations of interventions for the prevention of preterm labour of multiple births. It may be beneficial to regularly analyse data on multiple births so the interpretation of this data can inform learning and research. Safety actions Following stakeholder feedback received during an update of the guideline for preterm labour and birth, the National Institute for Health and Care Excellence decided to delete the recommendation relating to milking the cord and amend the subsequent recommendation on clamping of the cord to wait at least 60 seconds before clamping the cord of preterm babies unless there are specific maternal or fetal conditions that need earlier clamping.

This article and video tell the story of Rihan Neupane, a baby born prematurely in Dhapasi, Nepal, who was left in a vegetative state following a series of medical errors including a missed diagnosis of meningitis. His parents had chosen a private international hospital for their maternity care, but were let down by a series of medical errors including Rihan being mistakenly given a massive paracetamol overdose. Although external hospital safety inspectors found the hospital negligent on many counts, the hospital continued to deny any wrongdoing or responsibility for Rihan's condition. Rihan's father Sanjeev Neupane talks about his family's experience in the embedded video.

This nationwide study of over 1 million births in the English NHS between 2015 and 2017, published in The Lancet, has found large inequalities in pregnancy outcomes between ethnic and socioeconomic groups in England. The findings from Jardine et al. suggest that current national programmes to make pregnancy safer, which focus on individual women's risk and behaviour and their antenatal care, will not be enough to improve outcomes for babies born in England. The authors say that to reduce disparities in birth outcomes at a national level, politicians, public health professionals, and healthcare providers must work together to address racism and discrimination and improve women's social circumstances, social support, and health throughout their lives. Key findings Nationwide study of more than 1 million pregnancies in England finds that socioeconomic inequalities account for a quarter of stillbirths, a fifth of preterm births, and a third of births with fetal growth restriction—a condition in which babies are smaller than expected for their gestational age. South Asian and Black women living in the most deprived areas experience the largest inequalities in pregnancy outcomes. Estimates suggest that half of stillbirths and three-quarters of births with fetal growth restriction in South Asian women living in the most deprived 20% of neighbourhoods are potentially avoidable if this population had the same risks as white women living in the most affluent 20% of neighbourhoods. Similarly, about two-thirds of stillbirths and about half of births with fetal growth restriction in Black women from the most deprived neighbourhoods are potentially avoidable if they had the same risks as white women from the most affluent neighbourhoods. The authors call for concerted action by maternity services as well as public health professionals and politicians to protect women and their babies through a combination of population approaches and targeting high-risk groups, addressing both wider determinants of health (eg, poverty and structural racism) and specific risk factors (eg, maternal smoking).

This investigation by the Healthcare Safety Investigation Branch (HSIB) looks at the issue of emergency blood transfusions given to newborn babies who need resuscitation when they are born. If a baby has lost blood before or during birth, efforts to resuscitate them may be less effective because they may not have enough blood to carry the oxygen their body needs. Delays in the administration of a blood transfusion in this scenario can therefore result in brain injury caused by lack of oxygen to the baby’s brain. As its ‘reference case’, the investigation examined the experience of Alex and Robert, whose baby Aria was born by emergency caesarean section following an acute blood loss. Baby Aria required resuscitation and was given a blood transfusion before being transferred to the neonatal (newborn baby) unit. Baby Aria sadly died when she was two days old. Findings Findings of this investigation included: The administration of a blood transfusion as part of resuscitation requires a number of preparatory steps, including collecting the blood and undertaking various checks before using it. Inclusion in resuscitation training of a prompt for clinicians to consider the need for a transfusion, and to prepare for it if appropriate, may help reduce any delay. Involving members of neonatal teams (staff who specialise in the care of newborn babies) in multidisciplinary training in maternity units is not routine. Standardising their inclusion in such training would promote a shared understanding of relevant clinical information and ways of working. Recommendations The report makes the following safety recommendations: HSIB recommends that NHS Resolution, working with relevant specialities through the clinical advisory group, amends the maternity incentive scheme guidance for year five to include the neonatal team as one of the professions required to attend multi-professional training. HSIB recommends that the Resuscitation Council (UK)’s Newborn Life Support training course highlights that neonatal resuscitation teams should consider fetal blood loss in the event of neonatal resuscitation that includes chest compressions. In addition, this consideration should be included in the guidance to support the newborn life support algorithm.

The purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) was to help improve patient safety in relation to the instructions 999 call handlers give to women and pregnant people who are waiting for an ambulance because of an emergency during their pregnancy. The HSIB investigation reviewed the case of Amy, who was 39 weeks and 4 days pregnant with her first child. She contacted 999 after experiencing abdominal cramps and bleeding. While waiting for an ambulance to arrive, Amy received pre-arrival instructions which were generated through a clinical decision support system (CDSS) from a non-clinical call handler. Amy was then taken by ambulance to hospital where her baby, Benjamin, was delivered by emergency caesarean section. Amy had excessive blood loss due to a placental abruption and was admitted to the high dependency unit for 12 hours following the birth. Benjamin required resuscitation to help him breathe on his own, he was intubated, and he received 72 hours of therapeutic cooling. He spent 13 days in hospital. Initial maternity investigation Amy’s case formed one part of an initial investigation carried out by the HSIB maternity investigation programme. This investigation identified a potential patient safety risk regarding the pre-arrival instructions given to women/pregnant people by 999 call handlers while they wait for an ambulance. Aspects of the pre-arrival instructions did not align with UK evidence-based maternity guidance (for clinicians in a clinical setting). This was considered to present a risk of harm to women or pregnant people and/or babies. Similar concerns relating to maternity pre-arrival instructions given by 999 call handlers were identified in 15 HSIB maternity investigations. These were referred to HSIB’s national investigation programme for consideration for a national investigation. Findings Findings of this investigation included: There are two triage clinical decision support systems in use in England, which provide different pre-arrival instructions for the same maternity clinical scenario for women/pregnant people who are waiting for an ambulance to arrive. The different pre-arrival instructions across triage clinical decision support systems, for the same reported symptoms, have different clinical implications/risks, creating a ‘postcode lottery’ of care. Stakeholders acknowledged a gap in maternity emergency guidance relating to the non-visual, non-clinician-attended environment. The investigation found no evidence of a regulatory mechanism for 999 call handler pre-arrival instructions. Recommendations The report makes the following safety recommendations: HSIB recommends that the Department of Health and Social Care commissions the National Institute for Health and Care Excellence to work with relevant stakeholders to develop guidance for maternity emergencies in the non-visual, non-clinician-attended environment. HSIB recommends that the Department of Health and Social Care identifies a suitable regulatory mechanism to provide formal oversight of 999 maternity pre-arrival instructions across NHS-funded care in England. HSIB recommends that NHS England and NHS Improvement develops the content of the patient safety incident investigation (PSII) standards to further support cross-boundary investigations.

The NHS Race & Health Observatory (RHO) has published a rapid review into ethnic health inequalities across a range of areas. This report is the first of its kind to analyse the overwhelming evidence of ethnic health inequality through the lens of racism. The NHS has longstanding problems with ethnic inequalities in terms of access to, experiences of, and outcomes of healthcare. These issues are rooted in experiences of structural, institutional and interpersonal racism. The review focussed on priorities set by the RHO relating to ethnic inequalities in: mental healthcare maternal and neonatal healthcare digital access to healthcare genetic testing and genomic medicine the NHS workforce.

In this podcast, Gill Phillips speaks to Nadia Leake and Rachel Collum, parents of premature babies who had long stays in neonatal care after birth, about the importance of Family Integrated Care. Gill developed Whose Shoes?® as a tool to allow people to 'walk in other people's shoes'. Through a wide range of scenarios and topics, Whose Shoes?® helps groups explore many of the concerns, challenges and opportunities facing the different groups affected by the transformation of health and social care. Nadia Leake and Rachel Collum discuss the need for Family Integrated Care (FIcare) in neonatal intensive care units (NICU). FIcare is an approach that facilitates parents to be primary caregivers to their child while they are in NICU, allowing them to love and nurture their child. For it to work well, it requires a culture in the hospital that encourages bonding and family. Nadia and Rachel discuss their own experiences of FIcare, and of units where it has not yet been fully developed, and underline how the approach enables families to bond and supports better outcomes for premature babies. They also describe the power of social media in bringing parents together to understand and promote their role in their children's care while in hospital - as parents not visitors.

This report draws on data from the National Child Mortality Database (NCMD) to investigate how illness around the time of birth affects the health of children up to the age of 10, and to draw out learning and recommendations for service providers and policymakers. This report aims to understand patterns and trends in child deaths where an event before, or around, the time of birth had a significant impact on life, and the risk of dying in childhood. Key findings From a public health perspective, it is possible that neonatal illness contributes to 72% of all deaths under 10 years of age. Children who received additional care after birth (neonatal care) made up 83% of children who died before their 1st birthday, 38% of deaths in the next 4 years, and 27% of deaths between the ages of 5 and 9. For babies born alive, at or after 22 weeks gestation, who subsequently died before 10 years of age between 1 April 2019 and 31 March 2021, half of the deaths occurred in children over one month old. There is a clear association between childhood death following neonatal illness and learning disabilities. Over half of the children who died also had learning disabilities. Where deaths were found to be caused by a perinatal event, the majority (78%) were caused by prematurity-related conditions. 13% were caused by perinatal asphyxia, 4% were caused by a perinatally acquired infection, and 4% were due to other causes. Modifiable factors were identified in 34% of the deaths reviewed. The most common were smoking in pregnancy, lack of involvement of appropriate services, and maternal obesity.

For the fourth year, the Health Quality Council of Alberta (HQCA), in partnership with the Patient and Family Advisory Committee (PFAC), held the Patient Experience Awards programme to recognise and help spread knowledge about initiatives that improve the patient experience in accessing and receiving healthcare services in Alberta, Canada. Applications spanned all corners of the province and came from a wide variety of care settings, and ranged from “elegantly simple” to complex in nature. The initiatives described reflected the diverse healthcare needs of Albertans and were equally diverse in their approach to healthcare improvement. However, they all had one thing in common: A desire to make change and deliver a better patient and family member experience. The following four initiatives were selected to receive the HQCA’s 2019 Patient Experience Awards: NowICU Project, Neonatal Intensive Care Unit (NICU), Misericordia Community Hospital Rapid Access, Patient Focused Biopsy Clinic; Head and Neck Surgery, Pathology; University of Alberta Hospital Edmonton Prostate Interdisciplinary Cancer Clinic (EPICC), Northern Alberta Urology Centre Transitional Pain Service, South Health Campus Take a look at their presentations and find out more about these great initiatives.

This article in JAMA Internal Medicine looks at the impact of language barriers on healthcare safety and quality in the US. Research shows that language discordance between patients and healthcare professionals worsens health outcomes, especially when there are no available, affordable and adequate interpreter services. The article describes the case of a mother who tried to raise concerns about her newborn baby's breathing and had her concerns dismissed, likely because she was unable to speak English and therefore could not communicate sufficiently with midwives and doctors. The author, Tamara Huson, a doctor in Ohio, describes how she had to convince the NICU unit to take the baby in for observation. On arrival at NICU, the baby's condition quickly deteriorated and she was intubated to save her life. This near miss illustrates the impact of language discordance, and the author argues that statutory requirements for translation service in the US are not being fulfilled by healthcare providers which receive Medicare and Medicaid funding.

A three-year programme launched in February 2017 to support improvement in the quality and safety of maternity and neonatal units across England - formerly known as the Maternal and Neonatal Health Safety Collaborative. NHS Improvement aim to: improve the safety and outcomes of maternal and neonatal care by reducing unwarranted variation and provide a high quality healthcare experience for all women, babies and families across maternity and neonatal care settings in England contribute to the national ambition, set out in Better Birthsopens in a new window of reducing the rates of maternal and neonatal deaths, stillbirths, and brain injuries that occur during or soon after birth by 20% by 2020. The web page includes resources on: Improving the proportion of smoke-free pregnancy. Optimisation and stabilisation of the very preterm infant. Detection and management of diabetes in pregnancy. Early recognition and management of deterioration of mother or baby.