Near-miss events are really missed! Reflections on incident reporting in a department of pediatric surgery

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7 Citations (Scopus)

Abstract

Purpose The aim of this study was to evaluate the frequency of surgical and organizational events that occurred in the whole Department of Paediatric Surgery at Gaslini Children's Hospital through an incident-reporting system in order to identify the vulnerabilities of this system and improve it. Materials and methods This is a 6-month prospective observational study (1st January-1st July 2010) of all events (including surgical and organizational events, and near misses) that occurred in our department of surgery (pediatric surgery, orthopedics and neurosurgery units). Results Over a 6-month study period, 3,635 children were admitted: 1,904 out of 3,635 (52.4%) children underwent a surgical procedure. A total number of 111 adverse events and 4 near misses were recorded in 100 patients. A total of 108 (97.3%) adverse events occurred following a surgical procedure. Of 111 adverse events, 34 (30.6%) required re-intervention. Eighteen of 100 patients (18%) required a re-admission, and 18 of 111 adverse events (16.2%) were classified as organizational. Infection represented the most common event. Conclusions An electronic physician-reported event tracking system should be incorporated into all surgery departments to report more accurately adverse events and near misses. In this system, all definitions must be standardized and near misses should be considered as important as the other events, being a rich source of learning.

Original languageEnglish
Pages (from-to)405-410
Number of pages6
JournalPediatric Surgery International
Volume28
Issue number4
DOIs
Publication statusPublished - Apr 2012

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Risk Management
Pediatrics
Neurosurgery
Observational Studies
Orthopedics
Learning
Prospective Studies
Physicians
Infection

Keywords

  • Adverse event
  • Incident reporting
  • Near miss
  • Pediatric surgery
  • Risk management

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Surgery

Cite this

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title = "Near-miss events are really missed! Reflections on incident reporting in a department of pediatric surgery",
abstract = "Purpose The aim of this study was to evaluate the frequency of surgical and organizational events that occurred in the whole Department of Paediatric Surgery at Gaslini Children's Hospital through an incident-reporting system in order to identify the vulnerabilities of this system and improve it. Materials and methods This is a 6-month prospective observational study (1st January-1st July 2010) of all events (including surgical and organizational events, and near misses) that occurred in our department of surgery (pediatric surgery, orthopedics and neurosurgery units). Results Over a 6-month study period, 3,635 children were admitted: 1,904 out of 3,635 (52.4{\%}) children underwent a surgical procedure. A total number of 111 adverse events and 4 near misses were recorded in 100 patients. A total of 108 (97.3{\%}) adverse events occurred following a surgical procedure. Of 111 adverse events, 34 (30.6{\%}) required re-intervention. Eighteen of 100 patients (18{\%}) required a re-admission, and 18 of 111 adverse events (16.2{\%}) were classified as organizational. Infection represented the most common event. Conclusions An electronic physician-reported event tracking system should be incorporated into all surgery departments to report more accurately adverse events and near misses. In this system, all definitions must be standardized and near misses should be considered as important as the other events, being a rich source of learning.",
keywords = "Adverse event, Incident reporting, Near miss, Pediatric surgery, Risk management",
author = "Girolamo Mattioli and Edoardo Guida and Giovanni Montobbio and Prato, {Alessio Pini} and Marcello Carlucci and Armando Cama and Silvio Boero and Michelis, {Maria Beatrice} and Elio Castagnola and Ubaldo Rosati and Vincenzo Jasonni",
year = "2012",
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volume = "28",
pages = "405--410",
journal = "Pediatric Surgery International",
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T1 - Near-miss events are really missed! Reflections on incident reporting in a department of pediatric surgery

AU - Mattioli, Girolamo

AU - Guida, Edoardo

AU - Montobbio, Giovanni

AU - Prato, Alessio Pini

AU - Carlucci, Marcello

AU - Cama, Armando

AU - Boero, Silvio

AU - Michelis, Maria Beatrice

AU - Castagnola, Elio

AU - Rosati, Ubaldo

AU - Jasonni, Vincenzo

PY - 2012/4

Y1 - 2012/4

N2 - Purpose The aim of this study was to evaluate the frequency of surgical and organizational events that occurred in the whole Department of Paediatric Surgery at Gaslini Children's Hospital through an incident-reporting system in order to identify the vulnerabilities of this system and improve it. Materials and methods This is a 6-month prospective observational study (1st January-1st July 2010) of all events (including surgical and organizational events, and near misses) that occurred in our department of surgery (pediatric surgery, orthopedics and neurosurgery units). Results Over a 6-month study period, 3,635 children were admitted: 1,904 out of 3,635 (52.4%) children underwent a surgical procedure. A total number of 111 adverse events and 4 near misses were recorded in 100 patients. A total of 108 (97.3%) adverse events occurred following a surgical procedure. Of 111 adverse events, 34 (30.6%) required re-intervention. Eighteen of 100 patients (18%) required a re-admission, and 18 of 111 adverse events (16.2%) were classified as organizational. Infection represented the most common event. Conclusions An electronic physician-reported event tracking system should be incorporated into all surgery departments to report more accurately adverse events and near misses. In this system, all definitions must be standardized and near misses should be considered as important as the other events, being a rich source of learning.

AB - Purpose The aim of this study was to evaluate the frequency of surgical and organizational events that occurred in the whole Department of Paediatric Surgery at Gaslini Children's Hospital through an incident-reporting system in order to identify the vulnerabilities of this system and improve it. Materials and methods This is a 6-month prospective observational study (1st January-1st July 2010) of all events (including surgical and organizational events, and near misses) that occurred in our department of surgery (pediatric surgery, orthopedics and neurosurgery units). Results Over a 6-month study period, 3,635 children were admitted: 1,904 out of 3,635 (52.4%) children underwent a surgical procedure. A total number of 111 adverse events and 4 near misses were recorded in 100 patients. A total of 108 (97.3%) adverse events occurred following a surgical procedure. Of 111 adverse events, 34 (30.6%) required re-intervention. Eighteen of 100 patients (18%) required a re-admission, and 18 of 111 adverse events (16.2%) were classified as organizational. Infection represented the most common event. Conclusions An electronic physician-reported event tracking system should be incorporated into all surgery departments to report more accurately adverse events and near misses. In this system, all definitions must be standardized and near misses should be considered as important as the other events, being a rich source of learning.

KW - Adverse event

KW - Incident reporting

KW - Near miss

KW - Pediatric surgery

KW - Risk management

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