Keeping Tiny Babies Safe: Using the Lean Method (B)

An error occurs in the neonatal intensive care unit (NICU) where a breathing tube, also referred to as an endotracheal tube, becomes dislodged, causing a baby to decompensate (get sicker). The A case outlines the left side of an A3 Report put together by the NICU team. The B case concludes with a completed A3 Report and an action plan. This short case set highlights A3 problem-solving in health care. It is designed for classes on quality and safety in health care or any class focusing on A3 problem-solving. It is perfect for small group work during breakout sessions or for an in-class session with role-playing. At the University of Virginia Darden School of Business, it is taught in a health care elective called “Solutions and Innovations in Health Care.”