Table 1

 Errors detected during multidisciplinary work rounds

Category I audit questions*Errors detected per 100 patient days†Total no of errorsNo of days question audited
NICU, neonatal intensive care unit; CVC, central venous catheter; ND, not determined.
*Category I items: Median number of days the unit was audited for a given question = 7 (average unit census 19.5); average number of days the unit was audited for a given question = 7.1 (average unit census 19.5); range of number of days the unit was audited for a given question = 4–10 (average unit census 19.5).
†To calculate the number of errors per 100 patient days we divided the number of errors detected by a question during the study by the product of the average daily census (19.5) of the NICU and the number of days the question was audited. This number was multiplied by 100.
All patients rounded on were audited.
Blood/laboratory studies
    Was a blood/laboratory test ordered and not sent?2.349
    Was a blood/laboratory test drawn or sent on the wrong patient?0.619
    Did a blood/laboratory test need to be repeated due to a procedural problem?4.578
    Was a blood/laboratory specimen sent unlabeled or mislabeled with the wrong patient’s name?0.618
Radiology studies
    Was a radiological procedure ordered and not done?1.527
    Did an x ray or other procedure need to be repeated due to a procedural problem?0.717
    Was a requisition for a radiological procedure mislabeled?ND⩾14
Delays in patient service
    Was there a delay in informing parents of a “significant” clinical event or significant change in clinical status?1.739
    In the past 2 days, was a consultation ordered and not done?1.328
    Did a delay in reporting a laboratory test or radiology result affect clinical management?006
    Did a delay in responding to an alarm result in an adverse outcome?005
Information transfer
    Was important information that would affect the clinical management of a patient not transferred verbally or in writing?2.1410
    Were x rays/tests to be done on your shift not reported?007
Patient care equipment/medical devices
    Was a patient accidentally extubated?1.938
    Did a ventilator malfunction?0010
    Was a chest tube accidentally dislodged?009
    Did an alarm failure or malfunction cause a delay in treatment?005
    Was there an IV infiltrate that caused injury?4.145
    Did a CVC migrate or come out?0.717
Patient transport
    Did an adverse event occur while the patient was away from the NICU?005
    Were pain control measures during invasive procedures not used according to unit policy?1.015
    Pain not assessed before invasive procedures004
Errors detected⩾35