Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports

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 incidents pose the highest risk to patients in the NICU.

Design: Prospective multicenter 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. We describe 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 7 incident reports, and moderate harm in 63 incident reports. Incidents with mechanical ventilation and blood products were most likely to be assigned high risk scores, followed by parenteral nutrition, intravascular lines, and medication dosing errors.

Conclusions: Incidents occur much more frequently in our NICUs than previously observed, and their impact on patient morbidity is considerable. Reported incidents concerning mechanical ventilation, blood products, intravascular lines, parenteral nutrition, as well as medication dosing errors pose the highest risk to patients in the NICU.