FANTOMS
Fantoms
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Over recent years, we have carried a number of papers examining rates of adverse events in babies receiving intensive care. These have contained salutary reminders of the possible harms that can happen, and their frequency, but they have been less helpful in terms of generating and testing practical measures by which errors might be reduced. We would all sign up to the laudable aims of better education, tight and simple systems, and close monitoring of errors and learning from them when they occur, but even these do not reduce rates of error as far as we would all wish. So it is particularly valuable to have the paper by Lee et al bearing a very positive message by reporting the application of structured random safety audits (a system widely used in industry) to the NICU setting. In short: it demonstrably works, and other units should give serious consideration to emulating
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