Neonatal Intensive Care Unit (NICU) patients present unique patient identification challenges. Prospective hazard analysis (PHA) assesses safety by identifying hazards before an adverse event occurs. This project analyzes a barcoded feeding process in one NICU, and conducts a preliminary evaluation of PHA methods. Observations were conducted to quantify patient identification methods used in one NICU; the unit’s barcoded feeding process was examined for potential failures. The process underwent PHA with two methods, Global Hazard Ratings (GHR), a simplified method developed for this project, and Failure Modes and Effects Analysis (FMEA). FMEA showed greater interrater reliability; there was poor agreement between methods. A list of 21 hazards was developed for the clinical team from the FMEA results. Recommendations are for the unit to formulate and implement mitigation strategies for the identified hazards. Future work involves a more in depth look at FMEA interrater reliability and reliability comparison with other PHA methods.

Neonatal Intensive Care Unit (NICU) patients present unique patient identification challenges. Prospective hazard analysis (PHA) assesses safety by identifying hazards before an adverse event occurs. This project analyzes a barcoded feeding process in one NICU, and conducts a preliminary evaluation of PHA methods. Observations were conducted to quantify patient identification methods used in one NICU; the unit’s barcoded feeding process was examined for potential failures. The process underwent PHA with two methods, Global Hazard Ratings (GHR), a simplified method developed for this project, and Failure Modes and Effects Analysis (FMEA). FMEA showed greater interrater reliability; there was poor agreement between methods. A list of 21 hazards was developed for the clinical team from the FMEA results. Recommendations are for the unit to formulate and implement mitigation strategies for the identified hazards. Future work involves a more in depth look at FMEA interrater reliability and reliability comparison with other PHA methods.