Abstract
Background: Unplanned extubation (UE) is the fourth most common preventable adverse event in the Neonatal Intensive Care Unit (NICU). It results from many factors and leads to patient harm. There is limited evidence in identifying contributing factors of UE and more is needed to develop targeted UE prevention methods. Methods: A multidisciplinary work group performed post-event debriefings or mini root cause analysis (RCA) after each UE in the NICU from February 1st, 2016 through September 30th, 2016 and identified contributing factors. Based on these factors, the work …
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