AUTHOR=Brado Luise , Tippmann Susanne , Schreiner Daniel , Scherer Jonas , Plaschka Dorothea , Mildenberger Eva , Kidszun André 

TITLE=Patterns of Safety Incidents in a Neonatal Intensive Care Unit

JOURNAL=Frontiers in Pediatrics

VOLUME=Volume 9 - 2021

YEAR=2021

URL=https://www.frontiersin.org/journals/pediatrics/articles/10.3389/fped.2021.664524

DOI=10.3389/fped.2021.664524

ISSN=2296-2360

ABSTRACT=Introduction: Safety incidents preceding manifest adverse events are barely evaluated in the NICU. This study aimed at identifying frequency and patterns of safety incidents in our NICU.
 
Methods: A six-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 analysed. 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 to 12 (n=52, 26%) and 12 to 24 hours (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.