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“The fact is that most of the biggest catastrophes we’ve witnessed rarely come from information that is secret or hidden. They come from information that is freely available but that we are willfully blind to because we can’t handle the conflict that it provokes.”

Margaret Heffernan

The history of neonatology is replete with practitioners whose lifelong focus has been to improve the lives of newborn infants. Such focus predates the existence of neonatology (or, more officially, neonatal-perinatal medicine) as a subspecialty within the field of pediatrics. Indeed, the first significant premature neonatal outcomes project dates back to the 1870s, when famed Parisian perinatologist StéphaneTarnier pioneered and publicized the use of incubators (a derivative of chicken incubators) to save premature infants from hypothermia.1 Although incubators had also been designed by Tarnier’s contemporaries in the 19th century Russia and Germany, he claimed that his implementation of incubator use at the Paris Maternité hospital resulted in a drop in mortality for infants weighing 1,200 grams to 2,000 grams from 66 to 38%2—an impressive quality improvement project in any era.

One may ask why neonatologists then and now are so fixated on improving the safety of newborn intensive care unit (NICU) care and improving outcomes for our NICU graduates. This chapter will begin with highlighting some of the reasons that both the NICU itself and its patients are truly different from anywhere else in a hospital. Several examples of NICU collaboratives will then be discussed—groups existing at the local, state, national, and international levels formed primarily around the goals of providing opportunities for collaboration, generating new evidence, benchmarking, and dissemination of best practices. Next, the inherently multidisciplinary process of quality improvement within the NICU will be examined through three case studies: medication safety, central-line-associated bloodstream infections, and necrotizing enterocolitis. Finally, future opportunities for improving outcomes and reducing harm in the era of “big data” will be reviewed. But first, as it is impossible to predict the future without understanding the past, further discussion of the history of achievements in neonatal quality improvement will be provided.


In the world of medicine, neonatology is a relatively young subspecialty. Both the first board exam in neonatal-perinatal medicine and the first subspecialty meeting within the American Academy of Pediatrics occurred in 1975.3 Yet even before the field’s inception, its practitioners have been tightly and jointly focused on improving the quality of newborn critical care. Over 20 years before neonatology was recognized as an official subspecialty, Virginia Apgar (an obstetric anesthesiologist) standardized delivery room management with neonatology’s first “check-list”—the APGAR score.4 Since then, efforts to reduce harm and improve neonatal outcomes have yielded many of neonatology’s signature advances in the last 50 years, including:

  • ▪ The development of exogenous surfactant,

  • ▪ Hyperalimentation,

  • ▪ Miniaturization of blood testing volumes,

  • ▪ Continuous monitoring including pulse oximetry,

  • ▪ Methylxanthines for ...

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