Quality and Safety Indicators in Neonatal Care: An Integrative Review of Their Evolution

The neonatal intensive care unit (NICU) environment is characterised by demanding specialised care, complex technologies, and agile and assertive practice by the multidisciplinary team due to the profile of the neonatal patient. The prioritisation of neonatal patient safety has led to the development of quality tools that enable the monitoring of quality and safety through the operationalisation of a set of indicators across the continuum of care. The aim of the study was to critically analyse the evolution of quality and safety indicators used in neonatal care and discuss their applicability to the creation of a Neonatal Patient Safety Checklist (NPSC) based on developmental centred care (DCC).

An integrative review was conducted according to the methodology of Whittemore and Knafl, involving structured research using MeSH/DeCS and Boolean operators in the PubMed, Scopus, Web of Science, CINAHL, and SciELO databases. Empirical studies (qualitative, quantitative, or mixed methods) published in Portuguese, English, Spanish, or French between 2011 and 2023 were included. The report adhered to the PRISMA 2020 guidelines, and critical appraisal was conducted using the JBI, CASP, and MMAT grids where applicable. The synthesis mapped the indicators according to Donabedian's model (structure-process-outcome), with a focus on DCC.

Fourteen studies were included. There was a shift from a technoprocedural paradigm focussing on infection prevention, medication safety, and procedures, to an integrated approach combining safety culture, safe leadership, resource allocation, communication during transitions, structured records, and experiential metrics (e.g., parental satisfaction). This is consistent with DCC. The overall methodological quality was moderate to high. However, there are still gaps in the validation process (about content, reliability, and sensitivity to change), particularly with regard to experiential and parental indicators. There is also operational heterogeneity that limits comparability between NICU.

Conceptual advances have been made in measuring quality and safety in NICUs, with the progressive integration of DCC. Systematic incorporation of these indicators requires standardisation of definitions, structured records, and robust psychometric validation. The findings provide an operational basis for developing and implementing NPSC, which are useful for continuous improvement and decision support in NICU.