Using the Generic Analysis Method to Analyze Sentinel Event Reports Across Hospitals: A Retrospective Cross-Sectional Study.

Objectives: Improving patient safety by investigating sentinel events (SEs) is hampered by the focus on isolated events within hospitals and a narrow scope of traditional root cause analysis methods. We aimed to examine if performing cross-hospital aggregate analysis of SEs applying a novel generic analysis method (GAM) bearing a human factor perspective can enhance learning from SEs.

Methods: A retrospective cross-sectional review of SE reports from 28 Dutch general hospitals using the GAM to reanalyze events was performed.

Severe neonatal hyperbilirubinaemia: lessons learnt from a national perinatal audit.

Objectives: To describe characteristics of neonates with severe neonatal hyperbilirubinaemia (SNH) and to gain more insight in improvable factors that may have contributed to the development of SNH.

Design And Setting: Descriptive study, based on national Dutch perinatal audit data on SNH from 2017 to 2019.

Patients: Neonates, born ≥35 weeks of gestation and without antenatally known severe blood group incompatibility, who developed hyperbilirubinaemia above the exchange transfusion threshold.

Randomized Controlled Early versus Late Ventricular Intervention Study in Posthemorrhagic Ventricular Dilatation: Outcome at 2 Years.

Objective: To compare the effect of intervention at low vs high threshold of ventriculomegaly in preterm infants with posthemorrhagic ventricular dilatation on death or severe neurodevelopmental disability.

Study Design: This multicenter randomized controlled trial reviewed lumbar punctures initiated after either a low threshold (ventricular index of >p97 and anterior horn width of >6 mm) or high threshold (ventricular index of >p97 + 4 mm and anterior horn width of >10 mm). The composite adverse outcome was defined as death or cerebral palsy or Bayley composite cognitive/motor scores <-2 SDs at 24 months corrected age.

Treatment thresholds for intervention in posthaemorrhagic ventricular dilation: a randomised controlled trial.

Objective: To compare a low versus a higher threshold for intervention in preterm infants with posthaemorrhagic ventricular dilatation.

Design: Multicentre randomised controlled trial (ISRCTN43171322).

Setting: 14 neonatal intensive care units in six countries.

Withdrawal of a novel-design duodenoscope ends outbreak of a VIM-2-producing Pseudomonas aeruginosa.

Background And Study Aims: Infections are a recognized risk of endoscopic retrograde cholangiopancreatography (ERCP). This paper reports on a large outbreak of VIM-2-producing Pseudomonas aeruginosa that was linked to the use of a recently introduced duodenoscope with a specific modified design (Olympus TJF-Q180V).

Methods: Epidemiological investigations and molecular typing were executed in order to identify the source of the outbreak.

Critical incidents among intensive care unit nurses and their need for support: explorative interviews.

Aims: This article aims (a) to get insight into intensive care nurses' most critical work-related incidents, (b) their reactions and coping and (c) perceived support, in a Dutch intensive care unit.

Background: Research about the impact of critical incidents has largely been aimed at ambulance and emergency nurses; knowledge about intensive care nurses in this respect is scarce. Persistent stress reactions after critical incidents may cause symptoms of post-traumatic stress disorder, depression and anxiety.

[Fatal respiratory failure in a morbidly obese patient].

Background: Healthcare professionals are seeing an increasing number of morbidly obese patients. Medical interventions are often difficult to perform in these patients. In acute situations this can lead to major problems.

A literature review on flow-rate variability in neonatal IV therapy.

Aim: To provide an overview of factors influencing the flow rate in intravenous (IV) therapy for newborns.

Methods: We conducted a review of the literature from 1980 to 2011 in PubMed and Web of Knowledge. Articles focusing on flow-rate variability and possible complications due to flow-rate variability were included.

Parental involvement and kangaroo care in European neonatal intensive care units: a policy survey in eight countries.

Objective: To compare, in a large representative sample of European neonatal intensive care units, the policies and practices regarding parental involvement and holding babies in the kangaroo care position as well as differences in the tasks mothers and fathers are allowed to carry out.

Design: Prospective multicenter survey.

Setting: Neonatal intensive care units in eight European countries (Belgium, Denmark, France, Italy, The Netherlands, Spain, Sweden, and the United Kingdom).

"New-generation" pulse oximeters in extremely low-birth-weight infants: how do they perform in clinical practice?

The aim of this study was to evaluate the performance of "new-generation" pulse oximeters in extremely low-birth-weight ([ELBW] ≤ 1000 g) infants. In a prospective crossover observational study, the performance of pulse oximeters of 3 brands (Masimo, Nellcor, and Philips) was evaluated by dual SpO2 measurement in ELBW infants. Disposable probes of either equal or different brands were placed around both feet of the patient simultaneously for approximately 4 hours.

An observational study to quantify manual adjustments of the inspired oxygen fraction in extremely low birth weight infants.

Aim: To quantify manual fraction of inspired oxygen (FiO(2)) adjustments performed by caregivers in extremely low birth weight (ELBW; ≤1000 g) infants, in relation to oxygen saturation (SpO(2)) and bedside care.

Methods: In a single-centre study, FiO(2) , SpO(2) and alarm limits of ELBW infants were collected for 3 days continuously, while caregivers were filmed. A descriptive analysis, focused on manual FiO(2) adjustments, was performed.

Work-related critical incidents in hospital-based health care providers and the risk of post-traumatic stress symptoms, anxiety, and depression: a meta-analysis.

This meta-analysis reviewed existing data on the impact of work-related critical incidents in hospital-based health care professionals. Work-related critical incidents may induce post-traumatic stress symptoms or even post-traumatic stress disorder (PTSD), anxiety, and depression and may negatively affect health care practitioners' behaviors toward patients. Nurses and doctors often cope by working part time or switching jobs.

Heel blood sampling in European neonatal intensive care units: compliance with pain management guidelines.

Objective: To describe the use of heel blood sampling and non-pharmacological analgesia in a large representative sample of neonatal intensive care units (NICUs) in eight European countries, and compare their self-reported practices with evidence-based recommendations.

Methods: Information on use of heel blood sampling and associated procedures (oral sweet solutions, non-nutritive sucking, swaddling or positioning, topical anaesthetics and heel warming) were collected through a structured mail questionnaire. 284 NICUs (78% response rate) participated, but only 175 with ≥50 very low birth weight admissions per year were included in this analysis.

Polyalanine expansion in the ZIC3 gene leading to X-linked heterotaxy with VACTERL association: a new polyalanine disorder?

Background: The VACTERL association is a non-random association of congenital defects with an unknown aetiology in the majority of patients.

Methods: A male newborn is reported with features of the VACTERL association, including anal atresia, laryngeal and oesophageal atresia with tracheo-oesophageal fistula, dextroposition of the heart with persistent left superior vena cava, and unilateral multicystic kidney. As the clinical picture of this patient overlaps with that of X-linked heterotaxy caused by ZIC3 mutations, the ZIC3 coding region was sequenced.

Nasogastric tube position and intragastric air collection in a neonatal intensive care population.

Purpose: For neonates receiving intensive care, nasogastric tube feeding is essential. Since nasogastric tube placement techniques are not well standardized and common verification methods can be unreliable, placement errors may lead to unsafe situations. In mechanically ventilated neonates and neonates on continuous positive airway pressure, malpositioning of the nasogastric tube may prevent excess air within the stomach to escape.

Parents, siblings and grandparents in the Neonatal Intensive Care Unit. A survey of policies in eight European countries.

Objective: To describe policies towards family visiting in Neonatal Intensive Care Units (NICU) and compare findings with those of a survey carried out 10 years earlier.

Methods: A questionnaire on early developmental care practices was mailed to 362 units in eight European countries (Sweden, Denmark, the UK, the Netherlands, Belgium, France, Spain and Italy). Of them 78% responded, and among those responded, 175 reported caring for at least 50 very low birth weight infants every year and their responses were analysed further.

Communicating with Muslim parents: "the four principles" are not as culturally neutral as suggested.

The "four principles approach" has been popularly accepted as a set of universal guidelines for biomedical ethics. Based on four allegedly trans-cultural principles (respect for autonomy, nonmaleficence, beneficence and justice), it is supposed to fulfil the need of a 'culturally neutral approach to thinking about ethical issues in health care'. On the basis of a case-history, this paper challenges the appropriateness of communicating in terms of these four principles with patients with a different background.

Brain ultrasonography findings in neonates with exposure to cocaine during pregnancy.

Background: Cocaine exposure during pregnancy has been reported to have detrimental effects on the fetus.

Objective: To describe the findings on cranial ultrasonography (CUS) as part of a neonatal screening programme for exposed neonates.

Materials And Methods: The study was a semiprospective analysis of a 12-year cohort of neonates born to mothers who had used cocaine during their pregnancy and who had follow-up according to a strict clinical protocol.

A survey on job satisfaction among nursing staff before and after introduction of the NIDCAP model of care in a level III NICU in the Netherlands.

Purpose: To study the effect of introduction of the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) on nursing staff job satisfaction.

Subjects: Registered nurses, with specialist neonatal qualifications or in training, in a level III neonatal intensive care unit (NICU) in the Netherlands.

Design And Methods: A survey was performed before 2001 and 6 months after (2003) the introduction of NIDCAP as the new model of care.

Design and evaluation of a regional perinatal audit.

Objective: To describe the experiences of a regional audit of perinatal deaths, including the experiences of the audit members, to discuss similarities and differences with other, existing perinatal audits and to summarize the implications for future implementation.

Study Design: Perinatal audit with blinded regional auditors. Consecutive cases of perinatal death were analysed for the presence of substandard care.

Ethnic differences in perinatal mortality. A perinatal audit on the role of substandard care.

Objectives: The objective was to investigate the contribution of substandard care to ethnic inequalities in perinatal mortality.

Study Design: Perinatal audit in Amsterdam, the Netherlands. The study population consisted of 137 consecutive perinatal death cases (16 weeks GA-28 days after delivery).

Loss of integrity of thyroid morphology and function in children born to mothers with inadequately treated Graves' disease.

Context: Central congenital hypothyroidism (CH-C) in neonates born to mothers with inadequately treated Graves' disease usually needs T(4) supplementation. The thyroid and its regulatory system have not yet been extensively studied after T(4) withdrawal, until we observed disintegrated thyroid glands in some patients.

Objective: The aim was to study the occurrence and pathogenesis of disintegrated thyroid glands in CH-C patients.