Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports
- C Snijders1,2,
- R A van Lingen1,
- H Klip3,
- W P F Fetter4,
- T W van der Schaaf5,6,
- H A Molendijk1,
- on behalf of the NEOSAFE study group
- 1Princess Amalia Department of Paediatrics, Division of Neonatology, Isala Clinics, Zwolle, The Netherlands
- 2Juliana Children’s Hospital, Haga Hospital, The Hague, The Netherlands
- 3Research Bureau, Isala Clinics, Zwolle, The Netherlands
- 4Department of Paediatrics, Division of Neonatology, VU University Medical Center, Amsterdam, The Netherlands
- 5Division of Patient Safety, Hasselt University, Diepenbeek, Belgium
- 6Faculty of Technology Management, Eindhoven University of Technology, Eindhoven, The Netherlands
- C Snijders, Haga Hospital, Location Juliana Children’s Hospital, Sportlaan 600, 2566 MJ The Hague, The Netherlands; c.snijders{at}grimbergen.net
- Accepted 4 September 2008
- Published Online First 6 October 2008
Abstract
Objectives: To examine the characteristics of incidents reported after introduction of a voluntary, non-punitive incident reporting system for neonatal intensive care units (NICUs) in the Netherlands; and to investigate which types of reported incident pose the highest risk to patients in the NICU.
Design: Prospective multicentre survey.
Methods: Voluntary, non-punitive incident reporting was introduced in eight level III NICUs and one paediatric surgical ICU. An incident was defined as any unintended event which (could have) reduced the safety margin for the patient. Multidisciplinary, unit-based patient safety committees systematically collected and analysed incident reports, and assigned risk scores to each reported incident. Data were centrally collected for specialty-based analysis. This paper describes the characteristics of incidents reported during the first year. Bivariate logistic regression analysis was conducted to identify high-risk incident categories.
Results: There were 5225 incident reports on 3859 admissions, of which 4846 were eligible for analysis. Incidents with medication were most frequently reported (27%), followed by laboratory (10%) and enteral nutrition (8%). Severe harm was described in seven incident reports, and moderate harm in 63 incident reports. Incidents involving mechanical ventilation and blood products were most likely to be assigned high-risk scores, followed by those involving parenteral nutrition, intravascular lines and medication dosing errors.
Conclusions: Incidents occur much more frequently in Dutch NICUs than has been previously observed, and their impact on patient morbidity is considerable. Reported incidents concerning mechanical ventilation, blood products, intravascular lines, parenteral nutrition and medication dosing errors pose the highest risk to patients in the NICU.
Footnotes
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The NEOSAFE report form (online appendix A) is published online only at http://adc.bmj.com/content/vol94/issue3
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Funding: This study was supported by a grant from the Dutch Association of Medical Specialists.
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Competing interests: None.
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Ethics approval: The local medical research ethics committee (METC Zwolle) was consulted and confirmed that this study did not require approval for implementation as it only involved the registration of incidents.
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The NEOSAFE study group
Neonatal Intensive Care Units:
Academic Medical Center, Amsterdam: J H Kok, E te Pas; Erasmus MC-University Medical Center, Rotterdam: H Pas, C van der Starre; Haga Hospital, The Hague: E Bloemendaal, R H Lopes Cardozo, A M Molenaar; Isala Clinics, Zwolle: A Giezen, R A van Lingen, H E Maat, A Molendijk, C Snijders; Maastricht University Medical Center: S Lavrijssen, A L M Mulder; Máxima Medical Center, Veldhoven: M J K de Kleine, A M P Koolen, M Schellekens; Radboud University Medical Centre Nijmegen: W Verlaan, S Vrancken; VU University Medical Center, Amsterdam: W P F Fetter, L Schotman, A van der Zwaan
Paediatric Surgical Intensive Care Unit:
Erasmus MC-University Medical Center, Rotterdam: C van der Starre, Y van der Tuijn, D Tibboel
Other departments:
Division of Patient Safety, Hasselt University, Diepenbeek, Belgium, and Faculty of Technology Management, Eindhoven University of Technology: T W van der Schaaf; Research Bureau, Isala Clinics, Zwolle: H Klip, B J Kollen
