Implementing Strategies to Identify and Mitigate Adverse Safety Events: A Case Study with Unplanned Extubations.

BACKGROUND: Patient safety events result from failures in complex health care delivery processes. To ensure safety, teams must implement ways to identify events that occur in a nonrandom fashion and respond in a timely manner. To illustrate this, one children's hospital's experience with an outbreak of unplanned extubations (UEs) in the neonatal ICU (NICU) is described. METHODS: The quality improvement team measured UEs using three complementary data streams. Interventions to decrease the rate of UE were tested with success. Three statistical process control (SPC) charts (u-chart, g-chart, and an exponentially weighted moving average [EWMA] chart) were used for real-time monitoring. RESULTS: From July 2015 to May 2016, the UE rate was stable at 1.1 UE/100 ventilator days. In early June 2016, a cluster of UEs, including four events within one week, was observed. Two of three SPC charts showed special cause variation, although at different time points. The EWMA chart alerted the team more than two weeks earlier than the u-chart. Within days of discovering the outbreak, the team identified that the hospital had replaced the tape used to secure endotracheal tubes with a nearly identical product. After multiple tape products were tested over the next month, the team selected one that returned the system to a state of stability. CONCLUSION: Ongoing monitoring using SPC charts allowed early detection and rapid mitigation of an outbreak of UEs in the NICU. This highlights the importance of continuous monitoring using tools such as SPC charts that can alert teams to both improvement and worsening of processes.