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

  • Girolamo Mattioli
  • Edoardo Guida
  • Giovanni Montobbio
  • Alessio Pini Prato
  • Marcello Carlucci
  • Armando Cama
  • Silvio Boero
  • Maria Beatrice Michelis
  • Elio Castagnola
  • Ubaldo Rosati
  • Vincenzo Jasonni
Original Article



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).


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.


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.


Near miss Adverse event Incident reporting Risk management Pediatric surgery 


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Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • Girolamo Mattioli
    • 1
  • Edoardo Guida
    • 1
    • 7
  • Giovanni Montobbio
    • 2
  • Alessio Pini Prato
    • 1
  • Marcello Carlucci
    • 1
  • Armando Cama
    • 3
  • Silvio Boero
    • 4
  • Maria Beatrice Michelis
    • 4
  • Elio Castagnola
    • 5
  • Ubaldo Rosati
    • 6
  • Vincenzo Jasonni
    • 1
  1. 1.Pediatric Surgery Department, Giannina Gaslini InstituteUniversity of GenoaGenoaItaly
  2. 2.Anaesthesia and Intensive Care DepartmentGiannina Gaslini InstituteGenoaItaly
  3. 3.Neurosurgery DepartmentGiannina Gaslini InstituteGenoaItaly
  4. 4.Orthopedic Surgery DepartmentGiannina Gaslini InstituteGenoaItaly
  5. 5.Infectious Disease DepartmentGiannina Gaslini InstituteGenoaItaly
  6. 6.Quality Control OfficeGiannina Gaslini InstituteGenoaItaly
  7. 7.Pediatric Surgery DepartmentG. Gaslini Children’s Hospital, University of GenoaGenoaItaly

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