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Keeping newborn babies with a family history of MCADD safe in the first hours and days of life (Safety Alert No. 2)

Published: 09/09/2011

The National Patient Safety Agency (NPSA) regularly releases Rapid Response Reports (RRRs) as a response to safety issues that arise through normal reporting systems. These reports contain descriptions of clinical incidents, the potential ways to reduce the particular risks that lead to the incidents and, most usefully, tools to help system improvement.

The Safety and Quality Committee is frequently asked to advise on the content and relevance of these reports prior to publication. The current list of reports can be found here.

In particular, on 27 October 2011 the NPSA published an RRR entitled ‘Keeping newborn babies with a family history of MCADD [medium chain acyl-CoA dehydrogenase deficiency] safe in the first hours and days of life’. This report describes two deaths of newborn babies with this condition that were considered to be potentially preventable. Within the report are suggested ways to improve awareness, prevention and management of MCADD along with some tools to help change. This RRR can be found here.

The Safety and Quality Committee also makes the observation that, while the incidence of MCADD is very low, for those units that adopt the simple recommendations within the RRR there will be enhanced detection of families with other rare inherited diseases.