ArticleJoint Commission journal on quality and patient safety2019
Implementing Strategies to Identify and Mitigate Adverse Safety Events: A Case Study with Unplanned Extubations.
Article in Joint Commission journal on quality and patient safety, 2019. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 6 papers.
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Who cites it
6 citing papers in PubMed.
- Association of unplanned extubations and neurodevelopmental outcomes in very low birthweight infants.Journal of perinatology : official journal of the California Perinatal Association · 2025Article
- Risk Prediction of Unplanned Extubation in Inpatients Using Random Forest and Logistic Regression Models.Journal of patient safety · 2025Article
- Unplanned Extubations: Rare Event Monitoring for Continuous Quality Improvement.Respiratory care · 2023Article
- Experiences of a Regional Quality Improvement Collaborative to Reduce Unplanned Extubations in the Neonatal Intensive Care Unit.Children (Basel, Switzerland) · 2022Article
- Outcomes, Resource Use, and Financial Costs of Unplanned Extubations in Preterm Infants.Pediatrics · 2020Observational
- Enhancing Safety in Mechanical Ventilation: A Quality Improvement Initiative Targeting Unplanned Extubations in a Tunisian PICU.Pediatric quality & safetyArticle
Corrections and comments
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Authors and funding
8 authors.
Funding
Abstract
backgroundPatient 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.
methodsThe 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.
resultsFrom 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.
conclusionOngoing 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.
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