Being A NICU Safety Monkey

Jae Kim, MD, PhD / February 2015

When my kids were younger we played a very memorable PC computer game that would teach them about different situations that they might find themselves in. The characters would be seeking different adventures and just at the moment they would be thinking of doing something unsafe, a cartoon character called Safety Monkey would swing into action, come onto the scene and give a teachable lesson on how to play safe.

Like all favorite children’s videos or games this one still plays over and over in my head. No irony is lost now that I find myself as the Quality Improvement Representative (a.k.a. Safety Monkey) for our NICU.

Each time I walk into the NICU I observe situations or events that are precarious. Daily rounds on a sick patient are controlled chaos that involve a house staff who is presenting, an attending and fellow who are examining the infant, another house staff who is writing orders down, a pharmacist who is live cross-checking our orders, other caregivers who are reporting out their perspectives, all the while teaching moments are being highlighted and parents who have been present all along as part of family centered care are being spoken to in “parent speak” so they could understand the medical jargon that was said over their heads. And this goes on and on around the room. Our “bat phone,” or delivery phone, frequently rings off to fracture this routine, dissecting the people in the room and sending off smaller groups to the delivery with the remaining ones continuing doing what they were previously doing. Other scenes include, not uncommonly, tubes and lines dangling off a tiny micro preemie not more than the size of my hand as they are lifted off their bed for cares or to provide skin to skin care with parents.

Sometimes the scene in our NICU reminds me of watching a Cirque du Soleil show in Las Vegas or a Chinese acrobat show and feeling as if there is no way this is going to go well. So many times sensitive events take place in the NICU that make the charge of keeping to our own policies, clinical guidelines and best practices, and maintaining optimal dialogue with staff and parents a daunting task. The potential catastrophes that lurk line up behind one another like dominos ready to fall. I am reminded daily that entropy or chaos is the natural order of things and so systems that are not well managed simply break down.

That is why our patients are under such a tight order of management, clinical assessments, feeding schedules, medication delivery, radiographs, ultrasounds, rounding, parental contact, etc. Safety is a palpable concern in the NICU.

Fortunately, our team of professionals, like most NICUs in the country, perform an amazing dance routine day in and day out. We have developed enough routines that much of what we do is built into our subconscious and is automatic. This enables us to do such complex and varied tasks such that it may look dangerous to outsiders but to us it is “been there, done that.” Habits are a natural way for us to be able to add on more and more complex things to deal with without overloading our subconscious. We naturally develop routines and patterns that allow us to then bury that activity into our subconscious and permit conscious engagement in more immediate activities. This is a great evolutionary process that keeps us open to new situations.

The truth is, however, as long as we are human and prone to errors, mistakes are possible and inevitably are going to happen in the NICU. Just this week I had to tell parents that our team made a mistake and that we did not follow our own protocols to the letter. Some parents find it easy to forgive small mistakes while others want to hold us accountable to perfection. It is quite hard to stay on protocol for everything we do, never mind that we often don’t have exact protocols or guidelines for what we do.

NICU Safety Monkey img

I get most nervous about something going wrong in the NICU when the finely tuned team is challenged with the task of starting something different or new, whether it be use of a new drug or start of a new practice. These are the critical junctures where the process of accepting and adopting a new idea disrupts our normal behavior, often jarring our routine behavior to not feel normal anymore. I liken this to my amateur golf swing (much to be desired) but whenever I hear or read about a great pointer and attempt to implement it into my swing, I am suddenly conscious of the tens of other things going on with the mechanics of my swing, leaving me with a disrupted and disjointed swing until I can allow the new movements to sink back into the previous automated response.

I am particularly concerned about the great movement that we have had recently towards more human milk use in the NICU. There are a number of important effects in adopting a human milk culture that we all need to be aware of in order to avoid or minimize the errors fraught with this change. Developing good habits for human milk nutrition in the NICU takes considerable effort at first to establish the cues for the new practices. Making the changes we have been doing to introduce more and longer exposures to human milk, mother’s own and donor human milk, open up new opportunities for human error.

When I look at how we manage the handling of human milk in the NICU these days, I am quite concerned that we don’t own this process yet. When it comes to use of formula milk we are comfortable with what we are getting and delivering. Data are very clear that human milk is highly variable in macronutrient content, often varying more than two-fold from high to low energy content.1-3 Fat content can vary even 5-6 fold. In many respects we have better regulated milk from donor human milk banks that thoroughly screen mothers and their milk for potential risks to the infants. The downside however is that the milk quality suffers due to heat processing and the fact that the milk tends to be lower on average in protein compared with preterm milk. How many NICUs have adopted computerized milk tracking systems to be able to account for all the milk and milk handling, fortification, alterations, and delivery changes that take place? My sense is that this is still the minority. There is no question that we should have a feeding system that is safe and that cannot be mistaken for parenteral systems. Too many human error accidents have taken place to make this non-viable for the NICU environment. We need to remember too though that even a bullet-proof milk tracking system can still be beaten by a nurse or caregiver who wants to bypass that system.

Storage of human milk is another step that is increasingly challenging. Cold storage is always a premium in today’s hospitals. Recent data would support the use of fresh refrigerated milk for up to 96 hours from the time of pumping.4 If the practice of fresh milk use becomes pervasive, which it is not yet, we would need to struggle with issues of clear expiration dates for milk, greater refrigerated storage capacity for fresh milk and triaging of fresh versus frozen milk that may contain greater nutrient content.

Our ability to control the quality of mother’s own milk is incomplete. Our lactation director, Lisa Stellwagen, has told me of some occasions where certain bugs have infested electric pumps that mothers have used, taken home with them and returned to us. I have some pretty nasty images too of milk samples brought in by our mothers that contain floating particles or insect remnants.

Delivery of human milk is becoming more standardized with various enteral feeding systems available to us. More recently we are in the midst of significant changes with enteral feeding systems to standardize the connectors across different manufacturers. ( The end result should be a safer situation but my concern is this is another change event that is ripe for human errors to occur. I have been working with several small innovative companies that are trying to introduce enteral feeding products into the neonatal market. They are caught in the sea change of enteral feeding connectors and struggle, having to decide which connectors to go with in their design before a universal system is fully adopted. Remember Beta versus VHS?

Incorporating human milk use into the DNA of your NICU is going to take time and careful planning. The goal of improving the health outcomes of our infants is incentive enough, however. The more our community can share our experiences in standardizing and developing best practices to introduce human milk culture as well as other advances in care, particularly with the pitfalls we each have experienced should mitigate more human errors from happening. For now and the near future then there is still a need for safety monkeeeeey!!!!


1. Sauer CW, Kim JH. Human milk macronutrient analysis using point-of-care near-infrared spectrophotometry. J Perinatol. 2011 May;31(5):339-43. doi: 10.1038/jp.2010.123. Epub 2010 Nov 4. PubMed PMID: 21052045.

2. Henderson JJ, Hartmann PE, Newnham JP, Simmer K. Effect of preterm birth and antenatal corticosteroid treatment on lactogenesis II in women. Pediatrics. 2008 Jan;121(1):e92-100. doi: 10.1542/peds.2007-1107. PubMed PMID: 18166549.

3. Polberger S, Lönnerdal B. Simple and rapid macronutrient analysis of human milk for individualized fortification: basis for improved nutritional management of very-low-birth-weight infants? J Pediatr Gastroenterol Nutr. 1993
Oct;17(3):283-90. PubMed PMID: 8271128.

4. Slutzah M, Codipilly CN, Potak D, Clark RM, Schanler RJ. Refrigerator storage of expressed human milk in the neonatal intensive care unit. J Pediatr. 2010 Jan;156(1):26-8. doi: 10.1016/j.jpeds.2009.07.023. Epub . PubMed PMID: 19783003.


About the Author

Jae Kim is an academic neonatologist and pediatric gastroenterologist and nutritionist at UC San Diego Medical Center and Rady Children’s Hospital of San Diego. He has been practicing medicine for over 23 years both in Canada and the USA. He has published numerous journal articles, book chapters, and speaks nationally on a variety of neonatal topics. He is the Director for the Neonatal-Perinatal Medicine Fellowship Program at UC San Diego and the Nutrition Director of an innovative multidisciplinary program to advance premature infant nutrition called SPIN (Supporting Premature Infant Nutrition, He is the co-author of the book, Best Medicine: Human Milk in the NICU. Dr. Kim is a clinical consultant with Medela, Inc.