Managing Risk, Managing Fear

This issue of the Journal of Perinatal and Neonatal Nursing focuses on risk management and professional liability-topics almost guaranteed to raise the stress level of nursing professionals as they read. The combination of staffing shortages, the cost and poor availability of liability insurance, and the increasing technologic complexity of care make the provision of safe and competent nursing care more difficult every day. And in this climate, we need to be clear that how we perform our work manages the risks inherent in pregnancy, birth, and newborn care, rather than our fear of bad outcomes or lawsuits.

It is too simple to say that every known intervention should be applied in every case. As data from the Cochrane Reviews and many other sources reveal, too many or improperly chosen interventions can cause as much or more harm than they prevent. Further, we know that the natural course of labor has its own rhythms and benefits. When women are healthy, their ability to give birth needs to be respected rather than mistrusted.

In this issue, Rubeor defines the terms for us. Who is a risk manager? What do they do? What is their role when something goes wrong at a birth? Greenwald and Mondor then present 2 cases, identifying and discussing the risks that arise in each. Next, Simpson and Knox have produced a synthesis of commonly referenced "standards, policies, and guidelines" for events in the perinatal period. These are presented in the unusual format (for a journal) of annotated lists, which we hope maximizes their ease of use. Reading these 2 articles together can provide an opportunity for thoughtful consideration of practice in one's own facility. Finally, Miller discusses the lessons we can learn by drawing on the experiences of experts in other fields who are already applying the results of their work in standardization, human factors research, teambuilding, and information technology. Talking to ourselves is not adequate. We need to draw on others' knowledge as well.

All health care functions in systems. Systems are stronger when they are well examined, when evidence is valued, when they can be relied on to increase safety. But systems also can become so tradition-ridden that it is difficult to make changes. Improving quality always requires acknowledging the need for change, and then frontloading the changing system with training and new knowledge. It is a difficult challenge because it draws on resources that already have many competing demands. The reward is a stronger system that can help us work with a respect for, rather than a fear of, risk.

The articles in the neonatal section of this issue focus on several risk management and quality assurance issues. Burns discusses the issue of infant abduction in healthcare facilities from both well newborn areas and neonatal intensive care units. Although this is not a common problem, the risk of abduction is always present and represents an area of high liability when it occurs. Burns discusses the components of infant security systems and the process of evaluating and selecting such a system.

Most mothers of preterm infants will need to use a breast pump. The attachments from breast pump kits present a potential source of nosocomial infection for the infant. D'Amico, Di Nardo, and Krytofiak discuss the risk of contamination of breast pump kit attachments in the neonatal intensive care unit. They present a review of the current literature about breast pump contamination and recommendations for care of breast pump kit attachments to minimize the risks for nosocomial infections from this source. Several studies have reported that preterm infants are at risk for apnea, bradycardia, and oxygen desaturations when in car seats. As a result the American Academy of Pediatrics has recommended that infants less than 37 weeks gestational age be monitored in car seats before discharge. Williams and Martin examine the current status of implementation of this recommendation.