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 language | English |
|---|---|
| Pages (from-to) | 405-410 |
| Number of pages | 6 |
| Journal | Pediatric Surgery International |
| Volume | 28 |
| Issue number | 4 |
| DOIs | |
| Publication status | Published - Apr 2012 |
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Keywords
- Adverse event
- Incident reporting
- Near miss
- Pediatric surgery
- Risk management
ASJC Scopus subject areas
- Pediatrics, Perinatology, and Child Health
- Surgery
Cite this
Near-miss events are really missed! Reflections on incident reporting in a department of pediatric surgery. / Mattioli, Girolamo; Guida, Edoardo; Montobbio, Giovanni; Prato, Alessio Pini; Carlucci, Marcello; Cama, Armando; Boero, Silvio; Michelis, Maria Beatrice; Castagnola, Elio; Rosati, Ubaldo; Jasonni, Vincenzo.
In: Pediatric Surgery International, Vol. 28, No. 4, 04.2012, p. 405-410.Research output: Contribution to journal › Article
}
TY - JOUR
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
UR - http://www.scopus.com/inward/record.url?scp=84863506815&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=84863506815&partnerID=8YFLogxK
U2 - 10.1007/s00383-011-3047-5
DO - 10.1007/s00383-011-3047-5
M3 - Article
C2 - 22228073
AN - SCOPUS:84863506815
VL - 28
SP - 405
EP - 410
JO - Pediatric Surgery International
JF - Pediatric Surgery International
SN - 0179-0358
IS - 4
ER -