Abstract
This paper demonstrates the implementation of pH paper in to one neonatal unit, following the guidelines issued by the National Patient Safety Agency (NPSA) in August 2005. It describes the process that was used, discusses the documentation and reflects on the whole programme of events and with hindsight, what could have been improved. The change proved very challenging but was achieved successfully with a large workforce, by use of a communication-driven cascade approach based around key trainers.
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