4.13 A CRITICAL INCIDENT REPORTING SYSTEM AND AN ANALYSIS OF CRITICAL INCIDENTS IN A LEVEL 3 NEONATAL INTENSIVE CARE UNIT

J. A. Foy, D. Agarwal, S. Sen. Royal Gwent Hospital, Newport, UK

Introduction: Critical incident reporting in a neonatal intensive care unit is a vital part of clinical governance to improve the safety and quality of healthcare. Unfortunately these incidents are not analyzed regularly in any meaningful way to get feedback and effect improvements.

Methods: At this level 3 neonatal intensive care unit, a critical incident reporting system has been developed in which all reported critical incidents are analyzed at monthly multidisciplinary meetings. They are then entered on a database. Incidents are categorised into classes A–E (A, death/risk of death through to E, incident no injury or inconvenience). This database of 2 years (1 January 2005 to 31 December 2006) was analyzed to determine the causes and patterns in critical incidents.

Results: There were 256 discrete incidents reported during this period. Class A incidents accounted for 0.78%, class B 71.5%, class C 8.6%, class D 5.5% and class E 13.7%. 73.4% of incidents were reported by nurses and the rest by doctors. “Clinical” incidents accounted for 86.3% of all incidents, “non-clinical” for 12.1% and “organisational” for 1.5%. “Drug errors” accounted for 47.5% of “clinical” incidents and all were class B category. These included incorrect administration (34.3%), prescription errors (25.7%), missed doses (20.9%) among others. Root cause analysis showed that “accident” (8.6%), “non-adherence to protocol” (8.2%), “communication breakdown” (6.6%) were the commonest reasons for the incidents.

Conclusions: In our experience, the critical incident reporting system has been very effective in understanding the reasons for incidents and subsequent handling of such events. In the future it is hoped that the system will be instrumental in reducing them.