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Minerva Pediatrica 2014 February;66(1):1-6


language: English

The error in neonatal intensive care: a multicenter prospective study

De Franco S. 1, Rizzollo S. 1, Angellotti P. 2, Guala A. 2, Stival G. 3, Ferrero F. 1

1 NICU, Maggiore Hospital Università del Piemonte Orientale, Novara, Italy; 2 Department of Pediatrics Castelli Hospital, Verbania, Italy; 3 Department of Paediatrics, S.S. Trinità Hospital Borgomanero, Novara, Italy


Aim: During a nursing conference of the Northeaster Piedmont Neonatal Intensive and Subintensive Neonatal Units the error in pediatrics and neonatology was discussed and a follow-up work was proposed with the aim to understand how many, what type of errors and what kind of adverse event they cause in our clinical practice.
Methods: Through an anonymous “detection sheet” we detected the errors made between March 1 and April 30, 2010 in a NICU and 2 Subintensive therapies. The total number of patients was 166 for 2398 days of hospitalization.
Results: The total number of errors was 72, with a error of 0.43/patient. Forty-six patients had experienced at least 1 error (28% of patients) and more than a 16 (10% of our patients). There is a statistically significant correlation between days of hospitalization and the number of errors occurred (r=0.63 Sperman’s correlation, P<0.01); 48% and 53% of the errors in the NICU and Subintensive CU were related to medication administration.
Conclusion: The severe damage in the NICU was caused by errors more frequently related to vascular access while the only mistake that led to a serious incident in subintensive CU was determined by a monitoring error. Errors were most frequently attributed to inattention-distraction, less frequently have been attributed to a lack of experience or a state of excessive fatigue. The data of our study were made available to all staff in order to make operators more aware of the importance of working safely.

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