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

Archives of Disease in Childhood: Fetal and Neonatal Edition

Volumn 94, Issue 3, 2009, Pages

  Snijders, C ^a,b   Van Lingen, R A ^a   Klip, H ^a   Fetter, W P F ^c   Van Der Schaaf, T W ^d,e   Molendijk, H A ^a  

^a ISALA HOSPITAL   (Netherlands)

^b JULIANA CHILDREN S HOSPITAL   (Netherlands)

^c VU UNIVERSITY MEDICAL CENTER   (Netherlands)

^d HASSELT UNIVERSITY   (Belgium)

^e EINDHOVEN UNIVERSITY OF TECHNOLOGY   (Netherlands)

Author keywords

[No Author keywords available]

Indexed keywords

ACCIDENT PREVENTION; ARTICLE; ARTIFICIAL VENTILATION; BLOOD; CHILD HEALTH CARE; DOSE TIME EFFECT RELATION; ENTERIC FEEDING; EXTRACORPOREAL OXYGENATION; HIGH RISK PATIENT; HOSPITAL ADMISSION; HUMAN; INCIDENT REPORT; INTRAVENOUS DRUG ADMINISTRATION; LABORATORY; LEARNING; MEDICATION ERROR; MORBIDITY; NEWBORN; NEWBORN INTENSIVE CARE; PARENTERAL NUTRITION; PATIENT SAFETY; PEDIATRICS; PRIORITY JOURNAL; RISK ASSESSMENT; RISK REDUCTION; THERAPEUTIC ERROR; VOLUNTARY REPORTING;

DATA COLLECTION; HUMANS; INFANT; INFANT, NEWBORN; INFANT, PREMATURE; INTENSIVE CARE UNITS, NEONATAL; INTENSIVE CARE, NEONATAL; MEDICAL ERRORS; NETHERLANDS; PROSPECTIVE STUDIES; RISK MANAGEMENT;

EID: 67650072874     PISSN: 13592998     EISSN: 14682052     Source Type: Journal    
DOI: 10.1136/adc.2007.135020     Document Type: Article

References (31)

1. Wu AW, Pronovost P, Morlock L. ICU incident reporting systems. J Crit Care 2002;17:86-94.
2. Weingart SN, Wilson RM, Gibberd RW, et al. Epidemiology of medical error. BMJ 2000;320:774-777
3. Frey B, Kehrer B, Losa M, et al. Comprehensive critical incident monitoring in a neonatal-pediatric intensive care unit: experience with the system approach. Intensive Care Med 2000;26:69-74. (Pubitemid 30184463)
4. Aspden PH, Corrigan JM, Wolcott J. Patient safety: achieving a new standard for care. Washington DC: National Academies Press, 2004.
5. Leape LL. Reporting of adverse events. N Engl J Med 2002;347:1633-1638
6. Beckmann U, Baldwin I, Hart GK, et al. The Australian Incident Monitoring Study in Intensive Care: AIMS-ICU. An analysis of the first year of reporting. Anaesth Intensive Care 1996;24:320-329
7. Snijders C, van Lingen RA, Molendijk A, et al. Incidents and errors in neonatal intensive care: a review of the literature. Arch Dis Child Fetal Neonatal Ed 2007;92:F391-8. (Pubitemid 47436228)
8. Battles JB, Kaplan HS, Van der Schaaf TW, et al. The attributes of medical eventreporting systems. Experience with a prototype medical event-reporting system for transfusion medicine. Arch Pathol Lab Med 1998;122:231-238
9. Suresh G, Horbar JD, Plsek P, et al. Voluntary anonymous reporting of medical errors for neonatal intensive care. Pediatrics 2004;113:1609-1618 (Pubitemid 38697966)
10. Molendijk A, Borst K, van den Dolder R. [To err is human. Blamefree reporting increases transparency.] Medisch Contact 2003;43:1658-1661 (In Dutch.)
11. Kaplan HS, Rabin Fastman B. Organization of event reporting data for sense making and system improvement. Qual Saf Health Care 2003;12(suppl 2):ii68-72. (Pubitemid 37542043)
12. Sorra JS, Nieva VF. Hospital survey on patient safety culture. (Prepared by Westat, under Contract No 290-9609994). AHRQ Publication No 04-0041. Rockville MD: Agency for Healthcare Research and Quality, 2004.
13. Reason J. Human error: models and management. BMJ 2000;320:768-770
14. Kaplan HS, Battles JB, Van der Schaaf TW, et al. Identification and classification of the causes of events in transfusion medicine. Transfusion 1998;38:1071-1081 (Pubitemid 28549010)
15. Van der Schaaf TW, Habraken MMP. PRISMA-Medical: a brief description. Eindhoven: Eindhoven University of Technology, 2005. http://www.who.int/ patientsafety/taxonomy/PRISMA-Medical.pdf (accessed 11Aug 2008).
16. Twisk JWR. Applied multilevel analysis: a practical guide. Cambridge: Cambridge University Press, 2006.
17. Wright L, Van der Schaaf TW. Accident versus near miss causation: a critical review of the literature, an empirical test in the UK railway domain, and their implications for other sectors. J Hazard Mater 2004;111:105-110 (Pubitemid 38844545)
18. Barach P, Small SD. Reporting and preventing medical mishaps: lessons from nonmedical near miss reporting systems. BMJ 2000;320:759-763 (Pubitemid 30179427)
19. Nakajima K, Kurata Y, Takeda H. A web-based incident reporting system and multidisciplinary collaborative projects for patient safety in a Japanese hospital. Qual Saf Health Care 2005;14:123-129 (Pubitemid 40523857)
20. Frey B, Buettiker V, Hug MI, et al. Does critical incident reporting contribute to medication error prevention? Eur J Pediatr 2002;161:594-599
21. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001;285:2114-2120 (Pubitemid 32367829)
22. Simpson JH, Lynch R, Grant J, et al. Reducing medication errors in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed 2004;89:F480-2. (Pubitemid 39472312)
23. Chappell K, Newman C. Potential tenfold drug overdoses on a neonatal unit. Arch Dis Child Fetal Neonatal Ed 2004;89:F483-4. (Pubitemid 39472313)
24. Larsen GY, Parker HB, Cash J, et al. Standard drug concentrations and smart-pump technology reduce continuous-medication-infusion errors in pediatric patients. Pediatrics 2005;116:e21-5.
25. Needham DM, Thompson DA, Holzmueller CG, et al. A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS). Crit Care Med 2004;32:2227-2233 (Pubitemid 39491801)
26. Needham DM, Sinopoli DJ, Thompson DA, et al. A system factors analysis of "line, tube, and drain" incidents in the intensive care unit. Crit Care Med 2005;33:1701-1707
27. Durie M, Beckmann U, Gillies DM. Incidents relating to arterial cannulation as identified in 7525 reports submitted to the Australian Incident Monitoring Study (AIMS-ICU). Anaesth Intensive Care 2002;30:60-65 (Pubitemid 34162706)
28. Kunac DL, Reith DM. Identification of priorities for medication safety in neonatal intensive care. Drug Saf 2005;28:251-261 (Pubitemid 40364891)
29. Leonard MS, Cimino M, Shaha S, et al. Risk reduction for adverse drug events through sequential implementation of patient safety initiatives in a children's hospital. Pediatrics 2006;118:e1124-9. (Pubitemid 46393761)
30. Beckmann U, Bohringer C, Carless R, et al. Evaluation of two methods for quality improvement in intensive care: facilitated incident monitoring and retrospective medical chart review. Crit Care Med 2003;31:1006-1011 (Pubitemid 36444405)
31. Sharek PJ, Horbar JD, Mason W, et al. Adverse events in the neonatal intensive care unit. Development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs. Pediatrics 2006;118:1332-1340