title: Prevention of unplanned extubations in neonates through process standardization.
abstract: Unplanned extubation events (UPEs) in neonates are hazardous to patient safety. Our goal was to reduce UPE rate (#UPEs per 100 ventilator days) by 50% in 12 months at our 25-bed level III inborn unit.
  
  
  
  Baseline data were gathered prospectively for 7 months. Three Plan-Do-Study-Act (PDSA) cycles targeting main causes of UPEs were developed over the next 20 months. Causes of UPEs were analyzed using Pareto charts; and a U control chart was created with QI Charts(©). Standard rules for detecting special cause variation were applied.
  
  
  
  Mean UPE rate decreased from 16.1 to 4.5 per 100 ventilator days, a 72% decrease, exceeding our goal. Analysis of U-chart demonstrated special cause variation, with eight consecutive points below the mean. Improvement was sustained throughout the study period.
  
  
  
  UPEs in neonates can be reduced with process standardization and frontline staff education, emphasizing vigilant endotracheal tube (ETT) maintenance.
authors.affiliation: Division of Neonatology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA.
authors.forename: T D
authors.initials: TD
authors.lastname: Fontánez-Nieves
authors.affiliation: Division of Neonatology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA.
authors.forename: M
authors.initials: M
authors.lastname: Frost
authors.affiliation: Division of Neonatology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA.
authors.forename: E
authors.initials: E
authors.lastname: Anday
authors.affiliation: Division of Neonatology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA.
authors.forename: D
authors.initials: D
authors.lastname: Davis
authors.affiliation: Division of Hospital Medicine, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA.
authors.forename: D
authors.initials: D
authors.lastname: Cooperberg
authors.affiliation: Division of Neonatology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA.
authors.forename: A J
authors.initials: AJ
authors.lastname: Carey
mesh_terms: D060666:Airway Extubation / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal / Q000592:standards; D007442:Intubation, Intratracheal / Q000009:adverse effects / Q000379:methods / Q000592:standards; D008297:Male; D010043:Outcome and Process Assessment, Health Care; D010347:Patient Care Planning / Q000458:organization & administration; D018802:Patient-Centered Care / Q000592:standards; D011314:Preventive Health Services; D058996:Quality Improvement; D012307:Risk Factors; D013192:Staff Development / Q000379:methods