Kernicterus: A “never-event” in healthy term and near-term newborns

Kernicterus is a tragic and unacceptable outcome for jaundice in an otherwise healthy newborn. But as health care practices and attitudes have changed over the years, reemergence of kernicterus has been evident in the medical literature and in the community. Current practice management for jaundice is prone to misunderstanding and oversights. Not all health care providers are involved in the process and there was a loss of concern about potential bilirubin toxicity. To ensure patient safety, address the root causes of kernicterus, and enhance the human factor performance, a system-based approach to hyperbilirubinemia to prevent kernicterus is described.