Things that go wrong in the NICU

What is it?

A NICU manages babies who cannot yet manage themselves. That means lines, tubes, monitors, ventilators, infusions and constant adjustment, in patients who weigh a few hundred grams to a few kilograms.

The recurring categories of error are these.

Medication and dosing. Weight-based, small volumes, high-risk drugs. See medication errors. ²

Infection. Central lines and prolonged hospital stays are the main routes to late-onset infection. Prevention rests on hand hygiene and line care. ⁶

Feeding and nutrition. Advancing feeds, recognizing feeding intolerance, and identifying necrotizing enterocolitis early. ⁷

Airway and breathing. Tube position, unplanned extubation, ventilator settings, and oxygen targeting. ⁸

Monitoring and alarms. Alarms that are silenced, thresholds set too wide, or trends not acted on.

Screening not done on schedule. Head ultrasounds, eye screening, hearing screening, bilirubin and glucose all have schedules. ^{3 4 9}

Handover. Information lost between shifts or between teams.

Discharge. Leaving without a follow-up plan, without hearing results, or without the right equipment and training. ⁵

What does standard care look like?

Care at the right level. Levels of neonatal care are formally defined, and a baby should be cared for at a level matched to their needs, with transfer before birth where possible. ¹

Weight-based dosing with double-checking. ²

Screening on schedule. Head ultrasounds in very preterm babies, eye screening for retinopathy, newborn hearing screening, glucose screening by risk factor, and bilirubin by hour of age. ^{10 9 4 3}

Infection prevention, including hand hygiene and central line care. ⁶

Targeted oxygen, since both too little and too much cause harm. ¹¹

Human milk prioritized, including donor milk where available, given the association with lower rates of necrotizing enterocolitis. ⁷

A structured discharge process with criteria and a written follow-up plan. ⁵

What can go wrong?

A medication or dosing error. ²

A line infection, or infection not recognized early. ⁶

Feeding intolerance not acted on, so necrotizing enterocolitis advanced. ⁷

A breathing tube in the wrong position, or an unplanned extubation not managed quickly.

Oxygen not targeted, contributing to eye or lung injury. ¹¹

Screening missed. A head ultrasound not done, eye screening not done, hearing screening not done or the referral not followed up, glucose not checked in an at-risk baby, or bilirubin not measured against the thresholds. ^{9 4 3}

Enlarging ventricles not tracked after a brain bleed. ¹²

Care at a level that did not match the baby's needs, or transfer delayed. ¹

Discharge without a follow-up plan, or without hearing results, or without developmental follow-up arranged. ⁵

Whether any of this amounts to a departure from the standard takes a physician expert reading the whole record.

Which injuries can follow?

The injury follows the error.

• Neonatal sepsis and meningitis from infection. ⁶
• Necrotizing enterocolitis. ⁷
• Kernicterus from untreated jaundice. ³
• Low blood sugar brain injury. ⁴
• Hydrocephalus where enlarging ventricles were not tracked. ¹²
• Retinopathy of prematurity, from oxygen and from missed screening. ⁸
• Hearing loss identified late. ⁹
• HIE from a period of low oxygen. ¹³

What does this look like in the records?

Ask for the complete NICU record, which is large. Specify:

• Daily progress notes.
• The medication administration record, including the weight used for dosing. ²
• Nursing flow sheets, including vital signs and oxygen settings.
• Ventilator settings and blood gas results.
• Every imaging report with its date: head ultrasounds, MRI, X-rays. ¹⁰
• Every laboratory result with times, particularly bilirubin and glucose. ^{3 4}
• Screening results: hearing, eyes, newborn screen. ⁹
• The discharge summary and the written follow-up plan. ⁵

While you are still there

Keep your own log. Date, time, what was said, who said it. The NICU binder pack prints out with daily log sheets, a questions log and a medication log.

How to ask without becoming the difficult parent

Ask specific, answerable questions. "What is the plan for today?" "What are we watching for?" "What number would change the plan?" Those are the questions that get real answers and that help the team as much as you.

What can you do this week?

1. Request the complete labor and delivery record for you and your baby. The records request builder writes the letters for you.
2. Write down what you remember while it is fresh, using the delivery timeline builder.
3. Read how to read your labor and delivery records before the records arrive.
4. Check the deadline to file in your state with the statute of limitations lookup.