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Incidents and errors in neonatal intensive care: A review of the literature
  1. Cathelijne Snijders (c.snijders{at}
  1. Isala Clinics Zwolle, Netherlands
    1. Richard A van Lingen (r.a.van.lingen{at}
    1. Isala Clinics Zwolle, Netherlands
      1. Harry Molendijk (a.molendijk{at}
      1. Isala Clinics Zwolle, Netherlands
        1. Willem P F Fetter (w.fetter{at}
        1. VU University Medical Center, Amsterdam, Netherlands


          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.


          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 compared with a study using mandatory reporting. Multi-institutional reporting identified rare but important errors. A substantial number of incidents were potentially harmful. Using a system approach, many contributing factors were identified. Information regarding 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.

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

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