Objectives To systematically investigate the causes and severity of incidents with mechanical ventilation and intravascular catheters in neonatal intensive care units (NICUs) in the Netherlands, in order to develop effective strategies to prevent such incidents in the future.
Design Prospective multicentre survey.
Methods Inclusion criteria were: incidents with mechanical ventilation and intravascular catheters reported to a voluntary, non-punitive, incident-reporting system which had been systematically analysed using the Prevention Recovery Information System for Monitoring and Analysis (PRISMA)-Medical method. The type, severity and causes of incidents reported from 1 July 2005 to 31 March 2007 are described. Local interventions performed as a result of systematic analysis of incidents are also described.
Results 533 of 1306 (41%) reported incidents with mechanical ventilation and intravascular catheters (n=339/856 and n=194/450, respectively) had been PRISMA analysed and were included in the study. Four incidents resulted in severe harm, 18 in moderate harm and 222 in minor harm. Tube-related incidents accounted for the greatest proportion of harm. 1233 root causes were identified, with most being classified as human error (55%). Of the remaining failures, 20% were organisational, 16% technical, 6% patient-related and 4% unclassifiable. The majority of failures were rule-based errors.
Conclusion Incidents with mechanical ventilation and intravascular catheters occur regularly in NICUs, and frequently harm patients. Multicentre, systematic analysis increases our knowledge of these events. Continuous training and education of all NICU personnel is required, together with preventive strategies aimed at the whole system – including the technical and organisational environment – rather than at human failure alone.
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The NEOSAFE study group Neonatal intensive care units: Academic Medical Centre, Amsterdam: JH Kok MD PhD, E te Pas RN; Erasmus MC-University Medical Centre, Rotterdam: H Pas RN, C van der Starre MD; Haga Hospital, The Hague: E Bloemendaal RN, RH Lopes Cardozo MD PhD, AM Molenaar RN; Isala Clinics, Zwolle: A Giezen RN, RA van Lingen MD PhD, HE Maat RN, A Molendijk MD PhD, C Snijders MD; Maastricht University Medical Centre: S Lavrijssen RN, ALM Mulder MD PhD; Máxima Medical Centre, Veldhoven: MJK de Kleine MD PhD, AMP Koolen MD, M Schellekens RN; Radboud University Medical Centre Nijmegen: W Verlaan RN, S Vrancken MD; VU University Medical Centre, Amsterdam: WPF Fetter MD PhD, L Schotman RN, A van der Zwaan RN. Paediatric surgical intensive care unit: Erasmus MC-University Medical Centre, Rotterdam: C van der Starre MD, Y van der Tuijn RN, D Tibboel MD PhD; Other departments: Division of Patient Safety, Hasselt University, Diepenbeek, Belgium; and Faculty of Technology Management, Eindhoven University of Technology: TW van der Schaaf PhD; Research Bureau, Isala Clinics, Zwolle: H Klip PhD, BJ Kollen PhD.
Funding CS was supported by an unrestricted grant from the Dutch Association of Medical Specialists.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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