Pediatric Surgery International

, Volume 28, Issue 4, pp 405–410

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

Authors

  • Girolamo Mattioli
    • Pediatric Surgery Department, Giannina Gaslini InstituteUniversity of Genoa
    • Pediatric Surgery Department, Giannina Gaslini InstituteUniversity of Genoa
    • Pediatric Surgery DepartmentG. Gaslini Children’s Hospital, University of Genoa
  • Giovanni Montobbio
    • Anaesthesia and Intensive Care DepartmentGiannina Gaslini Institute
  • Alessio Pini Prato
    • Pediatric Surgery Department, Giannina Gaslini InstituteUniversity of Genoa
  • Marcello Carlucci
    • Pediatric Surgery Department, Giannina Gaslini InstituteUniversity of Genoa
  • Armando Cama
    • Neurosurgery DepartmentGiannina Gaslini Institute
  • Silvio Boero
    • Orthopedic Surgery DepartmentGiannina Gaslini Institute
  • Maria Beatrice Michelis
    • Orthopedic Surgery DepartmentGiannina Gaslini Institute
  • Elio Castagnola
    • Infectious Disease DepartmentGiannina Gaslini Institute
  • Ubaldo Rosati
    • Quality Control OfficeGiannina Gaslini Institute
  • Vincenzo Jasonni
    • Pediatric Surgery Department, Giannina Gaslini InstituteUniversity of Genoa
Original Article

DOI: 10.1007/s00383-011-3047-5

Cite this article as:
Mattioli, G., Guida, E., Montobbio, G. et al. Pediatr Surg Int (2012) 28: 405. doi:10.1007/s00383-011-3047-5

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 missAdverse eventIncident reportingRisk managementPediatric surgery

Copyright information

© Springer-Verlag 2012