Patterns of Safety Incidents in a Neonatal Intensive Care Unit
Introduction: Safety incidents preceding manifest adverse events are barely evaluated in neonatal intensive care units (NICUs). This study aimed at identifying frequency and patterns of safety incidents in our NICU. Methods: A 6-month prospective clinical study was performed from May to October 2019...
Saved in:
| Published in: | Frontiers in pediatrics Vol. 9; p. 664524 |
|---|---|
| Main Authors: | , , , , , , |
| Format: | Journal Article |
| Language: | English |
| Published: |
Frontiers Media S.A
10-06-2021
|
| Subjects: | |
| Online Access: | Get full text |
| Tags: |
Add Tag
No Tags, Be the first to tag this record!
|
| Summary: | Introduction:
Safety incidents preceding manifest adverse events are barely evaluated in neonatal intensive care units (NICUs). This study aimed at identifying frequency and patterns of safety incidents in our NICU.
Methods:
A 6-month prospective clinical study was performed from May to October 2019 in a German 10-bed level III NICU. A voluntary, anonymous reporting system was introduced, and all neonatal team members were invited to complete paper-based questionnaires following each particular safety incident. Safety incidents were defined as safety-related events that were considered by the reporting team member as a “threat to the patient's well-being” which “should ideally not occur again.”
Results:
In total, 198 safety incidents were analyzed. With 179 patients admitted, the incident/admission ratio was 1.11. Medication errors (
n
= 94, 47%) and equipment problems (
n
= 54, 27%) were most commonly reported. Diagnostic errors (
n
= 19, 10%), communication problems (
n
= 12, 6%), errors in documentation (
n
= 9, 5%) and hygiene problems (
n
= 10, 5%) were less frequent. Most safety incidents were noticed after 4–12 (
n
= 52, 26%) and 12–24 h (
n
= 47, 24%), respectively. Actual harm to the patient was reported in 17 cases (9%) but no life-threatening or serious events occurred. Of all safety incidents, 184 (93%) were considered to have been preventable or likely preventable. Suggestions for improvement were made in 132 cases (67%). Most often, implementation of computer-assisted tools and processes were proposed.
Conclusion:
This study confirms the occurrence of various safety incidents in the NICU. To improve quality of care, a graduated approach tailored to the specific problems appears to be prudent. |
|---|---|
| Bibliography: | ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23 Reviewed by: David Brandt, University Clinic Dresden, Germany; Sandra Horsch, Helios Kliniken, Germany This article was submitted to Neonatology, a section of the journal Frontiers in Pediatrics Edited by: Hans Fuchs, University of Freiburg Medical Center, Germany |
| ISSN: | 2296-2360 2296-2360 |
| DOI: | 10.3389/fped.2021.664524 |