Original Article

Pediatric Surgery International

, Volume 28, Issue 4, pp 405-410

First online:

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

  • Girolamo MattioliAffiliated withPediatric Surgery Department, Giannina Gaslini Institute, University of Genoa
  • , Edoardo GuidaAffiliated withPediatric Surgery Department, Giannina Gaslini Institute, University of GenoaPediatric Surgery Department, G. Gaslini Children’s Hospital, University of Genoa Email author 
  • , Giovanni MontobbioAffiliated withAnaesthesia and Intensive Care Department, Giannina Gaslini Institute
  • , Alessio Pini PratoAffiliated withPediatric Surgery Department, Giannina Gaslini Institute, University of Genoa
  • , Marcello CarlucciAffiliated withPediatric Surgery Department, Giannina Gaslini Institute, University of Genoa
  • , Armando CamaAffiliated withNeurosurgery Department, Giannina Gaslini Institute
  • , Silvio BoeroAffiliated withOrthopedic Surgery Department, Giannina Gaslini Institute
  • , Maria Beatrice MichelisAffiliated withOrthopedic Surgery Department, Giannina Gaslini Institute
  • , Elio CastagnolaAffiliated withInfectious Disease Department, Giannina Gaslini Institute
    • , Ubaldo RosatiAffiliated withQuality Control Office, Giannina Gaslini Institute
    • , Vincenzo JasonniAffiliated withPediatric Surgery Department, Giannina Gaslini Institute, University of Genoa

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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

Near miss Adverse event Incident reporting Risk management Pediatric surgery