Please use this identifier to cite or link to this item:
http://hdl.handle.net/1942/9778
Title: | Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports | Authors: | Snijders, C. van Lingen, R. A. Klip, H. Fetter, W. P. F. VAN DER SCHAAF, Tjerk Molendijk, Harry A. |
Issue Date: | 2009 | Publisher: | B M J PUBLISHING GROUP | Source: | ARCHIVES OF DISEASE IN CHILDHOOD-FETAL AND NEONATAL EDITION, 94(3). p. F210-F215 | 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. | Notes: | Locat Juliana Childrens Hosp, Haga Hosp, NL-2566 MJ The Hague, Netherlands. [Snijders, C.; van Lingen, R. A.; Molendijk, H. A.] Isala Clin, Princess Amalia Dept Paediat, Div Neonatol, Zwolle, Netherlands. [Snijders, C.] Haga Hosp, Juliana Childrens Hosp, The Hague, Netherlands. [Klip, H.] Isala Clin, Res Bur, Zwolle, Netherlands. [Fetter, W. P. F.] Vrije Univ Amsterdam, Med Ctr, Dept Paediat, Div Neonatol, Amsterdam, 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. | Document URI: | http://hdl.handle.net/1942/9778 | ISSN: | 1359-2998 | e-ISSN: | 1468-2052 | DOI: | 10.1136/adc.2007.135020 | ISI #: | 000265951300012 | Category: | A1 | Type: | Journal Contribution | Validations: | ecoom 2010 |
Appears in Collections: | Research publications |
Show full item record
SCOPUSTM
Citations
35
checked on Sep 3, 2020
WEB OF SCIENCETM
Citations
33
checked on Sep 27, 2024
Page view(s)
68
checked on Jun 28, 2023
Google ScholarTM
Check
Altmetric
Items in DSpace are protected by copyright, with all rights reserved, unless otherwise indicated.