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Neonatal resuscitation | Signal

Reference number
1162 A
Issue date26 February 2010

This Signal relates to the failure or delay in resuscitating neonates due to equipment failing or missing from the resuscitation trolley, difficulty by staff in using equipment and drug errors (including adult strength epinephrine).


Passage through the birth canal is a hypoxic experience for the fetus as respiratory exchange at the placenta is prevented for the duration of the contraction. Though most babies tolerate this well, some do need help to establish normal breathing . Some babies are also born critically ill, for example following meconium aspiration or prolonged apnoea, or preterm birth. These babies will require rapid intervention.


Effective resuscitation requires technically complex skills and effective team working under pressure. For this reason, simulation techniques can be useful to prepare staff for the challenges of resuscitation. Some resuscitation problems relate to clinical skills and training, but other important issues relate to the safety of the environment. For example, this can include equipment not being present, or mistakes in selecting and stocking the appropriate medication on the crash trolley.


A typical incident report reads:
Crash called to ward. Anaesthetic SpR also called at the same time. Paediatric SHO not bleeped or called. Baby on resuscitaire in corridor, suction not working, replacement found but was delayed. Neopuff stopped working during resuscitation, changed to ambubag. Oxygen ran out during resuscitation, continued on air until oxygen made available from second resuscitaire.


Following a trigger incident, 11 related incidents of serious harm and death where equipment issues or drug error were listed as factors were identified from the Reporting and Learning System (RLS) database. However, as these were scenarios where babies needed resuscitation, it is difficult to know whether outcome can be attributed to error. In total, 622 incidents were identified within the RLS as relating to problems with equipment and medicines in neonatal resuscitation. In a sample of 100 lower harm incidents, two-thirds related to medical equipment and a third related to problems with medication. The two main themes regarding equipment were items missing from the trolley and oxygen not working or running out. The most serious medication incidents related to incorrect dose of epinephrine, including two incidents of ten fold errors and only adult strength, i.e. 1:1,000, available on the trolley.


The National Reporting and Learning Service (NRLS) has been discussing these data with the UK Resuscitation Council (RC), which provides training standards for staff and licenses centres to run RC (UK) approved Neonatal Life Support (NLS) courses. Initiatives include access to approved neonatal specific training for all clinical staff who are likely to be involved in neonatal resuscitation and embedding this in commissioning tools such as the 2009 Department of Health ‘Toolkit for High-Quality Neonatal Services’. In addition, the RC (UK) is considering a business proposal to redesign the neonatal resuscitation trolley/kit with design input (Helen Hamlyn Centre). This follows earlier work to develop safety features for the adult resuscitation trolley including open lay out, touch screen technology to guide the resus lead and facilitate the logging of interventions, and electronic tagging of equipment to maintain stock control. 

Have you had any incidents like this?
How many relevant staff have had up to date Resus Council approved neonatal life support training?
Do you have any local investigations which you could send to us (anonymised) at rrr@npsa.nhs.uk


Relevant to: children, neonatal care

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