Concerned that newborns are being discharged or transferred before their routine health screenings and immunization records are complete, neonatology nurse Pamela Donohue audited discharge reports of NICU patients and a random sampling of “well-baby nursery” infants. Director of clinical research in the NICU, Donohue and her team found incomplete transfer notes, and significant lapses in conducting and recording newborn metabolic and hearing screenings, eye exams and vaccinations.

“In our acute-care setting, these routine health-maintenance issues get lost,” she says. “We may all be sub-specialists, but we're pediatricians first. We have to pay attention to the general well-baby issues, too.”

The neonatology team is developing a monitoring system to close these gaps. Among its patient-safety initiatives is a new electronic template that requires complete health-maintenance information to process a transfer. "Incomplete, undocumented medical information compromises patient safety and care,” says Donohue. “Community pediatricians, who will follow these babies, need complete reports.”