Prevention of unplanned extubations in neonates through process standardization

Tania Dayane Fontanez-Nieves, M. Frost, E. Anday, D. Davis, D. Cooperberg, A. J. Carey

Research output: Contribution to journalArticle

9 Scopus citations


Objective:Unplanned extubation events (UPEs) in neonates are hazardous to patient safety. Our goal was to reduce UPE rate (#UPEs per 100 ventilator days) by 50% in 12 months at our 25-bed level III inborn unit.Study Design:Baseline data were gathered prospectively for 7 months. Three Plan-Do-Study-Act (PDSA) cycles targeting main causes of UPEs were developed over the next 20 months. Causes of UPEs were analyzed using Pareto charts; and a U control chart was created with QI Charts. Standard rules for detecting special cause variation were applied.Result:Mean UPE rate decreased from 16.1 to 4.5 per 100 ventilator days, a 72% decrease, exceeding our goal. Analysis of U-chart demonstrated special cause variation, with eight consecutive points below the mean. Improvement was sustained throughout the study period.Conclusion:UPEs in neonates can be reduced with process standardization and frontline staff education, emphasizing vigilant endotracheal tube (ETT) maintenance.Journal of Perinatology advance online publication, 21 January 2016; doi:10.1038/jp.2015.219.

Original languageEnglish (US)
JournalJournal of Perinatology
StateAccepted/In press - Jan 21 2016


ASJC Scopus subject areas

  • Obstetrics and Gynecology
  • Pediatrics, Perinatology, and Child Health

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