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Incidents and errors in neonatal intensive care: a review of the literature
  1. C Snijders1,
  2. R A van Lingen1,
  3. A Molendijk1,
  4. W P F Fetter2
  1. 1Princess Amalia Department of Paediatrics, Division of Neonatology, Isala Clinics
    Zwolle, The Netherlands
  2. 2Department of Paediatrics, Division of Neonatology, VU University Medical Centre
    Amsterdam, The Netherlands
  1. Dr C Snijders, Princess Amalia Department of Paediatrics, Division of Neonatology, Isala Clinics, Sophia, PO Box 10400, 8000 GK Zwolle, The Netherlands; c.snijders{at}


Objectives: To examine the characteristics of incident reporting systems in neonatal intensive care units (NICUs) in relation to type, aetiology, outcome and preventability of incidents.

Methods: Systematic review. Search strategy: Medline, Embase, Cochrane Library. Included: relevant systematic reviews, randomised controlled trials, observational studies and qualitative research. Excluded: non-systematic reviews, expert opinions, case reports and letters. Participants: hospital units supplying neonatal intensive care. Intervention: none. Outcome: characteristics of incident reporting systems; type, aetiology, outcome and preventability of incidents.

Results: No relevant systematic reviews or randomised controlled trials were found. Eight prospective and two retrospective studies were included. Overall, medication incidents were most frequently reported. Available data in the NICU showed that the total error rate was much higher in studies using voluntary reporting than in a study using mandatory reporting. Multi-institutional reporting identified rare but important errors. A substantial number of incidents were potentially harmful. When a system approach was used, many contributing factors were identified. Information about the impact of system changes on patient safety was scarce.

Conclusions: Multi-institutional, voluntary, non-punitive, system based incident reporting is likely to generate valuable information on type, aetiology, outcome and preventability of incidents in the NICU. However, the beneficial effects of incident reporting systems and consecutive system changes on patient safety are difficult to assess from the available evidence and therefore remain to be investigated.

  • intensive care
  • neonatal
  • medical errors
  • incident reporting system
  • NICU
  • patient safety

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  • Funding: CS was funded by the Dutch Association of Medical Specialists.

  • Competing interests: None.

  • Abbreviations:
    adverse drug events
    Institute of Medicine
    neonatal intensive care unit