Safety spotlight
We investigate maternity and newborn safety events to identify learning and prevent recurrence. This World Patient Safety Day provides an opportunity for us to share insights and promote safer practices. Our investigations into therapeutic cooling practices have identified areas of learning in relation to passive cooling.
These include:
- Resuscitaires being switched off whilst active resuscitation is ongoing.
- Resuscitaires being switched off after successful resuscitation but with no continuous recording of temperature as recommended by national guidance.
- Delays in starting continuous rectal temperature monitoring in babies admitted to the neonatal units for cooling.
This was first published in the Stakeholder Bulletin: September 2025 edition
Consider the following safety prompts:
- Is your local guidance in line with national guidance in relation to cooling practices?
- Do you have rectal probes or equipment available to ensure continuous temperature monitoring prior to starting passive cooling?
- What training do staff have in relation to passive cooling?