Provisional unicentric experience with an electronic incident reporting form in pediatric anesthesia

Giovanni Montobbio, Alessio Pini-Prato, Edoardo Guida, Nicola Disma, Leila Mameli, Stefano Avanzini, Roberto Scali, Pietro Tuo, Vincenzo Jasonni, Girolamo Mattioli

Research output: Contribution to journalArticlepeer-review


Objective: To present and compare with literature our experience with an electronic anesthesia-related incident reporting form as a quality control measure at Gaslini Children's Hospital over a 19-month period. Methods: All events that occurred between March 2009 and September 2010 were recorded. We adopted an electronic reporting form included in the online recording process of every anesthetic procedure. Events were divided into near misses and adverse events. Adverse events were further divided into incidents, minor events, and major events. Patients were divided into three age-groups: 3 years. Results: A total of 12 850 anesthetics were performed. Eight (0.06%) near misses and 108 (0.8%) adverse events were reported. Adverse events occurred more frequently in infants. Of 108 events, 35 (32.4%), 61 (56.5%), and 12 (11.1%) were classified as incidents, minor, and major events, respectively. Of all the adverse events, 66 (61%) were respiratory, 27 (25%) organizational, six (5%) drug-related, four (4%) cardiocirculatory, and five (5%) miscellaneous. Conclusions: Infants were at the highest risk to experience adverse events. Although experimental electronic incident reporting proved to be feasible, there is reason to suspect that there was underreporting of near misses. Overreporting of near miss events may be enhanced by easier and more straightforward reporting forms as well as by better education for anesthetic providers about the importance of recognizing and reporting near misses.

Original languageEnglish
Pages (from-to)1080-1086
Number of pages7
JournalPaediatric Anaesthesia
Issue number11
Publication statusPublished - Nov 2012

ASJC Scopus subject areas

  • Anesthesiology and Pain Medicine
  • Pediatrics, Perinatology, and Child Health


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