The error in neonatal intensive care: a multicenter prospective study. De Franco, S.; Rizzollo, S.; Angellotti, P.; Guala, A.; Stival, G.; and Ferrero, F. Minerva Pediatrica, 66(1):1--6, February, 2014. 00003
abstract   bibtex   
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\textless0.01); 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.
@article{de_franco_error_2014,
	title = {The error in neonatal intensive care: a multicenter prospective study},
	volume = {66},
	issn = {0026-4946},
	shorttitle = {The error in neonatal intensive care},
	abstract = {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{\textless}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.},
	language = {eng},
	number = {1},
	journal = {Minerva Pediatrica},
	author = {De Franco, S. and Rizzollo, S. and Angellotti, P. and Guala, A. and Stival, G. and Ferrero, F.},
	month = feb,
	year = {2014},
	pmid = {24608576},
	note = {00003 },
	keywords = {Humans, Infant, Newborn, Intensive Care, Neonatal, Medical Errors, Prospective Studies},
	pages = {1--6}
}
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