Abstract
Background: Patient safety is a spearhead of the University Medical Centre of Utrecht (UMCU), the Netherlands. It recognizes that human error is inevitable. Wherever possible, the system should be (re)designed in such a way that human error is discovered or intercepted before it leads to patient harm. Reporting incidents is part of the patient safety program running in our hospital. The Neonatal Intensive Care Unit (NICU) of the UMCU wanted to have more insight in the incident reports on their unit. By analysing the reports with NICU professionals, the chance of effective improvement on the department would be increased.
Aim: Increase of patient safety by incident analyses.
Method: Our NICU started a multi disciplinary local report committee. Procedures for analysing reports were made. In the analyses we looked at organisational factors, human errors and technical failures. Moreover we used ‘why questions’ and the ‘barrier analysis’.
Implications for practice: Local reporting needs support by management. It is necessary that all disciplines are represented in the committee and that members are approachable and are ambassadors for incident reporting. Regular feedback and presenting results to management and medical and nursing staff, stimulates reporting. Work instructions after exchanging mother milk, a new feeding application form and ongoing attention for the administration of extra oxygen are examples which resulted in fewer incidents.
Conclusion: After three years incident reporting became more regular. The reports increased from 37 in 2006 to 138 in 2009. Meanwhile a number of procedures has been adapted and improved, as a result of which patient safety increased.
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Van Der Stok, F., De Vos, J. & Van Den Hoogen, A. 470 Patient Safety in the Nicu. Pediatr Res 68 (Suppl 1), 240–241 (2010). https://doi.org/10.1203/00006450-201011001-00470
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DOI: https://doi.org/10.1203/00006450-201011001-00470