Moving Forward to Improve Safety and Quality of Neonatal Intensive Care in Korea

On December 16, 2017, four preterm infants died consecutively in 81 minutes in the neonatal intensive care unit (NICU) of Ewha Womans University Mokdong Hospital, Seoul, Korea, which triggered an immediate police investigation.1 Combining the results of the epidemiological investigation by the Korea Centers for Disease Control and Prevention and those of the autopsies conducted by the National Forensic Service, the police have concluded that the four newborn infants died of sepsis, caused by hospital-acquired infection with multidrug-resistant Citrobacter freundii. According to the report of the investigation, this antibiotic-resistant C. freundii was found in blood cultures taken from three infants prior to their deaths, confirmed as the same genetic sequence, as well as in the lipid solution administered to these four infants prior to death. The autopsies finally confirmed the presence of the same bacterium in the blood of all four infants. Therefore, it was suspected that the infections occurred because the lipid solutions intravenously infused to these 4 patients were already contaminated or contaminated in the preparation process before infusion in the NICU.2 Based on circumstantial evidence, the police are suspecting that bacterial contamination might have occurred during the process of preparation of small volums before infusion from one original 500 mL Smoflipid® bottle by nurses in the NICU. In addition, only two residents were covering not only the NICU but also the pediatric general wards and the emergency room simultaneously on night duty when cardiopulmonary resuscitation occurred consecutively for these 4 newborn infants who ultimately died in the NICU.3 Finally, five medical staff, two doctors and three nurses who cared for those patients were charged and booked with involuntary manslaughter. 2 However, the exact route of infection is not confirmed and the investigation is still underway at present.