Kernicterus (chronic and permanent sequelae of bilirubin toxicity) is largely preventable, yet tragic cases still occur in the United States each year. Key patient safety issues that have been identified in these cases include lack of knowledge regarding proper identification and management of hyperbilirubinemia among clinicians, lack of appropriate evaluation of babies who appear jaundiced, miscommunication about the status of the baby among members of the healthcare team, inadequate education for parents before discharge concerning what to do and whom to call if their baby becomes jaundiced, language barriers in making sure parents fully understand the information that is provided, and lack of appropriate follow-up in a timely manner after the baby is discharged from the hospital.

All healthcare providers should have a working knowledge of the recommendations in the Clinical Practice Guideline "Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation," published by the American Academy of Pediatrics (AAP, 2004) and supported by the Joint Commission on Accreditation of Healthcare Organizations (2004) in Sentinel Event Alert Number 31 "Revised Guidelines to Help Prevent Kernicterus." A clinical algorithm for management of jaundice in the newborn nursery and detailed explanations for each of the recommendations are provided by AAP (2004a). Patient instructions are available at no charge from AAP (2004b) in English, Spanish, Italian, and Chinese.

It is critically important that clinical practice in perinatal units and primary care provider offices be consistent with the recommendations in these publications (summarized in the box) to ensure the safest care possible for newborn babies. Although kernicterus is rare, the resultant damage to the baby is devastating. This type of injury should not happen in the United States.

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