Neonatal near-miss audits: a systematic review and a call to action.

P.B Medeiros; C. Bailey; D. Pollock; H. Liley; A. Gordon; C. Andrews; V. Flenady

Review

Neonatal near-miss audits: a systematic review and a call to action.

January 10, 2024

Medeiros PB, Bailey C, Pollock D, et al. BMC Pediatr. 2023;23(1):573.

View more articles from the same authors.

Near-miss events are often underreported, despite presenting opportunities for organizational learning and system changes. This systematic review identified no studies evaluating the effectiveness of neonatal near-miss audits for reducing perinatal morbidity and mortality, underscoring the need for well-designed, ethical studies examining this research question.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

August 4, 2021

Parent engagement in perinatal mortality reviews: an online survey of clinicians from six high-income countries.

March 3, 2021

The association of acute COVID-19 infection with Patient Safety Indicator-12 events in a multisite healthcare system.

May 25, 2022

Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020.

September 23, 2020

A multi-site assessment of inpatient safety event rates during the coronavirus disease 2019 pandemic.

January 18, 2023

Prescription opioid dose reductions and potential adverse events: a multi-site observational cohort study in diverse US health systems.

November 29, 2023

Improving prescription drug warnings to promote patient comprehension.

January 20, 2010

The quality, safety and content of telephone and face-to-face consultations: a comparative study.

June 2, 2010

Helping patients simplify and safely use complex prescription regimens.

March 16, 2011

Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016

March 3, 2017

Preventing home medication administration errors.

March 14, 2022

Recommendations to improve the usability of drug–drug interaction clinical decision support alerts.

November 25, 2015

Using social and behavioural science to support COVID-19 pandemic response.

June 3, 2020

Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient order errors: a randomized clinical trial.

May 29, 2019

How often do prescribers include indications in drug orders? Analysis of 4 million outpatient prescriptions.

July 10, 2019

Computerized prescriber order entry–related patient safety reports: analysis of 2522 medication errors.

October 19, 2016

Do patients who read visit notes on the patient portal have a higher rate of "loop closure" on diagnostic tests and referrals in primary care? A retrospective cohort study.

January 17, 2024

Teamwork on inpatient medical units: assessing attitudes and barriers.

May 5, 2010

"To err is human" but disclosure must be taught: a simulation-based assessment study.

February 28, 2018

A Department of Medicine infrastructure for patient safety and clinical quality improvement.

December 20, 2017

Effectiveness of acute care remote triage systems: a systematic review.

February 5, 2020

US emergency department visits attributed to medication harms, 2017-2019.

October 20, 2021

Fatal errors in nitrous oxide delivery.

January 2, 2008

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

Appropriate prescribing of medications: an eight-step approach.

February 7, 2007

Evaluating a patient safety learning laboratory to create an interdisciplinary ecosystem for health care innovation.

July 13, 2022

Checking anaesthetic equipment 2012: Association of Anaesthetists of Great Britain and Ireland.

May 23, 2012

Screening for adverse drug events: a randomized trial of automated calls coupled with phone-based pharmacist counseling.

March 6, 2019

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.

November 16, 2022

A patient-centered prescription drug label to promote appropriate medication use and adherence.

January 18, 2017

Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association.

August 21, 2013

Patterns of nurse–physician communication and agreement on the plan of care.

June 9, 2010

Use of paediatric early warning systems in Great Britain: has there been a change of practice in the last 7 years?

February 26, 2014

Challenging authority during a life-threatening crisis: the effect of operating theatre hierarchy.

December 19, 2012

Ethical considerations and patient safety concerns for cancelling non-urgent surgeries during the COVID-19 pandemic: a review.

May 12, 2021

Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care.

January 23, 2019

Discrepancies between clinical diagnoses and autopsy findings in critically ill children: a prospective study.

March 15, 2017

Errors during the preparation of drug infusions: a randomized controlled trial.

August 22, 2012

Assessment of changes in visits and antibiotic prescribing during the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use and the COVID-19 Pandemic.

July 20, 2022

Enhancing psychological safety in mental health services.

June 9, 2021

Medication reconciliation and hypertension control.

March 24, 2010

Liquid medication errors and dosing tools: a randomized controlled experiment.

October 5, 2016

Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency.

May 31, 2017

Families as partners in hospital error and adverse event surveillance.

March 8, 2017

Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists.

March 1, 2023

Human factors in anaesthesia: a narrative review.

February 15, 2023

The effect of audible alarms on anaesthesiologists' response times to adverse events in a simulated anaesthesia environment: a randomised trial.

June 18, 2014

Prevalence of adverse events in the hospitals of five Latin American countries: results of the 'Iberoamerican Study of Adverse Events' (IBEAS).

August 10, 2011

Patient-led training on patient safety: a pilot study to test the feasibility and acceptability of an educational intervention.

September 4, 2013

How well do incident reporting systems work on inpatient psychiatric units?

September 5, 2018

Curriculum development and implementation of a national interprofessional fellowship in patient safety.

September 5, 2018

Inappropriate preinjury warfarin use in trauma patients: a call for a safety initiative.

May 18, 2016

Readiness of US general surgery residents for independent practice.

October 4, 2017

Preparing clinicians for transitioning patients across care settings and into the home through simulation.

July 25, 2018

Trends and patterns in reporting of patient safety situations in transplantation.

February 10, 2016

Variation in caregiver perceptions of teamwork climate in labor and delivery units.

July 5, 2006

How strong is the evidence for the use of perioperative beta blockers in non-cardiac surgery? Systematic review and meta-analysis of randomised controlled trials.

September 7, 2005

Exclusion of residents from surgery-intensive care team communication: a qualitative study.

April 27, 2016

An alternative strategy for studying adverse events in medical care.

March 27, 2005

Pictograms, units and dosing tools, and parent medication errors: a randomized study.

July 19, 2017

Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices.

July 29, 2009

Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems.

January 28, 2015

Outbreak investigation of COVID-19 among residents and staff of an independent and assisted living community for older adults in Seattle, Washington.

June 10, 2020

Eradicating central line–associated bloodstream infections statewide: the Hawaii experience.

November 16, 2011

Computerized surveillance for adverse drug events in a pediatric hospital.

October 7, 2009

Increased mortality associated with after-hours and weekend admission to the intensive care unit: a retrospective analysis.

April 20, 2011

A randomized trial of a multifactorial strategy to prevent serious fall injuries.

July 29, 2020

Low rate of completion of recommended tests and referrals in an academic primary care practice with resident trainees.

January 31, 2024

Completion of recommended tests and referrals in telehealth vs in-person visits.

December 6, 2023

Urgent referrals from primary care to dermatology for lesions suspicious for skin cancer: patterns, outcomes, and need for systems improvement.

December 7, 2022

Development and pilot testing of guidelines to monitor high-risk medications in the ambulatory setting.

August 11, 2010

Health care professionals' perceptions of unprofessional behaviour in the clinical workplace.

March 1, 2023

Eliminating central line-associated bloodstream infections: a national patient safety imperative.

January 15, 2014

Disclosing harmful mammography errors to patients.

December 16, 2009

Outcomes of missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis, and sepsis in five pediatric hospitals.

September 13, 2023

Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections.

August 25, 2010

We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation adaptations.

March 17, 2021

Inter-rater reliability of a classification system for hospital adverse drug event reports.

September 12, 2007

Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis.

December 21, 2005

Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum?

April 5, 2006

Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care.

October 27, 2021

The vulnerabilities of computerized physician order entry systems: a qualitative study.

December 9, 2015

Nighttime cross-coverage is associated with decreased intensive care unit mortality. A single-center study.

September 3, 2014

Lessons learned in implementing a chronic opioid therapy management system.

December 21, 2022

Ten principles for more conservative, care-full diagnosis.

October 10, 2018

Perspectives about racism and patient-clinician communication among black adults with serious illness.

July 26, 2023

Point prevalence of surgical checklist use in Europe: relationship with hospital mortality.

February 25, 2015

Comparison of intensive care unit medication errors reported to the United States' MedMarx and the United Kingdom's National Reporting and Learning System: a cross-sectional study.

May 29, 2013

Incidence and types of adverse events and negligent care in Utah and Colorado.

March 27, 2005

Beyond the prescription: medication monitoring and adverse drug events in older adults.

August 31, 2011

Guideline for opioid therapy and chronic noncancer pain.

May 31, 2017

Using a machine learning system to identify and prevent medication prescribing errors: a clinical and cost analysis evaluation.

December 18, 2019

A pilot study examining undesirable events among emergency department–boarded patients awaiting inpatient beds.

April 8, 2009

Undermining and bullying in surgical training: a review and recommendations by the Association of Surgeons in Training.

October 14, 2015

Organisational culture: variation across hospitals and connection to patient safety climate.

January 5, 2011

A case of the birth and death of a high reliability healthcare organisation.

June 22, 2005

A theoretical framework and competency-based approach to improving handoffs.

May 28, 2008

Resident uncertainty in clinical decision making and impact on patient care: a qualitative study.

April 16, 2008

Health information technology and hospital patient safety: a conceptual model to guide research.

August 28, 2013

Swimming against the tide: primary care physicians' views on deprescribing in everyday practice.

August 23, 2017

Related Resources

"Black Women Should Not Die Giving Life": The lived experiences of Black women diagnosed with severe maternal morbidity in the United States.

April 17, 2024

The intersection of traumatic childbirth and obstetric racism: a qualitative study.

February 7, 2024

A combined assessment tool of teamwork, communication, and workload in hospital procedural units.

January 17, 2024

Factors influencing second victim experiences and support needs of OB/GYN and pediatric healthcare professionals after adverse patient events.

January 17, 2024

Sustained decrease in latent safety threats through regular interprofessional in situ simulation training of neonatal emergencies.

January 17, 2024

Respectful Maternity Care: Dissemination and Implementation of Perinatal Safety Culture to Improve Equitable Maternal Healthcare Delivery and Outcomes.

January 10, 2024

Quality and reporting of large-scale improvement programmes: a review of maternity initiatives in the English NHS, 2010–2023.

December 13, 2023

The racial disparities in maternal mortality and impact of structural racism and implicit racial bias on pregnant Black women: a review of the literature.

December 6, 2023

'Nobody cared': Women who have reported mistreatment while giving birth say CDC report validates their trauma. Advocates call for systemic change in treatment of pregnant people.

December 6, 2023

Team experiences of the root cause analysis process after a sentinel event: a qualitative case study.

November 29, 2023

Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care.

October 11, 2023

Vital signs: maternity care experiences — United States, April 2023.

September 6, 2023

Hiding in plain sight: inconvenient facts for patient safety in non-24/7 theatre on-site staffed obstetric units.

September 6, 2023

Amid lack of accountability for bias in maternity care, a California family seeks justice.

August 16, 2023

Toolkits To Reduce Hypertension in Pregnancy and Obstetric Hemorrhage.

August 16, 2023

Investigating racial and ethnic disparities in maternal care at the system level using patient safety incident reports.

August 9, 2023

Advancing Diagnostic Excellence in Maternal Health Care.

July 27, 2023 - July 27, 2023

Statewide perinatal quality improvement, teamwork, and communication activities in Oklahoma and Texas.

July 26, 2023

Trends in maternal mortality and severe maternal morbidity during delivery-related hospitalizations in the United States, 2008 to 2021.

July 12, 2023

Causes for medical errors in obstetrics and gynaecology.

June 28, 2023

A call for safety: anticipating and mitigating risk across an obstetrics and gynecology service line.

June 21, 2023

Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs Decision.

June 7, 2023

Why do so many Black women die in pregnancy? One reason: doctors don't take them seriously.

May 31, 2023

Psychosocial processes in healthcare workers: how individuals' perceptions of interpersonal communication is related to patient safety threats and higher-quality care.

May 31, 2023

Racial and ethnic disparities in obstetric and gynecologic care and role of implicit biases.

May 18, 2023

Listen to the whispers before they become screams: addressing Black maternal morbidity and mortality in the United States.

May 3, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Tools for establishing a sustainable safety culture within maternity services: a retrospective case study.

April 26, 2023

Strengthening open disclosure after incidents in maternity care: a realist synthesis of international research evidence.

April 12, 2023

Addressing Medical Gaslighting to Improve Maternal Health—Together.

March 29, 2023

See More About The Topic

Neonatology and Intensive Care

Neonatal near-miss audits: a systematic review and a call to action.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Neonatal near-miss audits: a systematic review and a call to action.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site