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Title: Feasibility and reliability of PRISMA-Medical for specialty-based incident analysis
Authors: Snijders, C.
Klip, H.
Lingen, R. A. van
Fetter, W. P. F.
Molendijk, A.
Issue Date: 2009
Source: QUALITY & SAFETY IN HEALTH CARE, 18(6). p. 486-494
Abstract: Aims and objectives: In this study, the feasibility and reliability of the Prevention Recovery Information System for Monitoring and Analysis (PRISMA)-Medical method for systematic, specialty-based analysis and classification of incidents in the neonatal intensive care unit (NICU) were determined. Methods: After the introduction of a Neonatology System for Analysis and Feedback on Medical Events (NEOSAFE) in eight tertiary care NICUs and one paediatric surgical ICU, PRISMA-Medical was started to be used to identify root causes of voluntary reported incidents by multidisciplinary unit patient safety committees. Committee members were PRISMA-trained and familiar with the department and its processes. In this study, the results of PRISMA-analysis of incidents reported during the first year are described. At t = 3 months and t = 12 months after introduction, test cases were performed to measure agreement at three levels of root cause classification using PRISMA-Medical. Inter-rater reliability was determined by calculating generalised kappa values for each level of classification. Results: During the study period, 981 out of 1786 eligible incidents (55%) were analysed for underlying root causes. In total, 2313 root causes were identified and classified, giving an average of 2.4 root causes for every incident. Although substantial agreement (kappa 0.70-0.81) was reached at the main level of root cause classification of the test cases (discrimination between technical, organisational and human failure) and agreement among the committees at the second level (discrimination between skill-based, rule-based and knowledge-based errors) was acceptable (kappa 0.53-0.59), discrimination between rule-based errors (the third level of classification) was more difficult to assess (kappa 0.40-0.47). Conclusion: With some restraints, PRISMA-Medical proves to be both feasible and acceptably reliable to identify and classify multiple causes of medical events in the NICU.
Notes: [Snijders, C.] Haga Hosp, Juliana Childrens Hosp, NL-2566 MJ The Hague, Netherlands. [Snijders, C.; Molendijk, A.] Isala Clin, Div Neonatol, Princess Amalia Dept Paediat, Zwolle, Netherlands. [van der Schaaf, T. W.] Hasselt Univ, Div Patient Safety, Diepenbeek, Belgium. [van der Schaaf, T. W.] Eindhoven Univ Technol, Fac Technol Management, NL-5600 MB Eindhoven, Netherlands. [Klip, H.] Isala Clin, Res Bur, Zwolle, Netherlands. Vrije Univ Amsterdam, Med Ctr, Div Neonatol, Dept Paediat, Amsterdam, Netherlands.
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ISSN: 1475-3898
DOI: 10.1136/qshc.2008.028068
ISI #: 000272324100016
Category: A1
Type: Journal Contribution
Validations: ecoom 2010
Appears in Collections:Research publications

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