Prevention of unplanned extubations in neonates through process standardization

Objective: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.study design: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.result: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.conclusion:upes in neonates can be reduced with process standardization and frontline staff education, emphasizing vigilant endotracheal tube (ett) maintenance.