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Near-miss events are really missed! Reflections on incident reporting in a department of pediatric surgery

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Abstract

Purpose

The aim of this study was to evaluate the frequency of surgical and organizational events that occurred in the whole Department of Paediatric Surgery at Gaslini Children’s Hospital through an incident-reporting system in order to identify the vulnerabilities of this system and improve it.

Materials and methods

This is a 6-month prospective observational study (1st January–1st July 2010) of all events (including surgical and organizational events, and near misses) that occurred in our department of surgery (pediatric surgery, orthopedics and neurosurgery units).

Results

Over a 6-month study period, 3,635 children were admitted: 1,904 out of 3,635 (52.4%) children underwent a surgical procedure. A total number of 111 adverse events and 4 near misses were recorded in 100 patients. A total of 108 (97.3%) adverse events occurred following a surgical procedure. Of 111 adverse events, 34 (30.6%) required re-intervention. Eighteen of 100 patients (18%) required a re-admission, and 18 of 111 adverse events (16.2%) were classified as organizational. Infection represented the most common event.

Conclusions

An electronic physician-reported event tracking system should be incorporated into all surgery departments to report more accurately adverse events and near misses. In this system, all definitions must be standardized and near misses should be considered as important as the other events, being a rich source of learning.

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Acknowledgments

The authors would like to thank Mrs. Francesca Roncallo for her valuable organizational and data retrieval support.

Author information

Authors and Affiliations

  1. Pediatric Surgery Department, Giannina Gaslini Institute, University of Genoa, Genoa, Italy

    Girolamo Mattioli, Edoardo Guida, Alessio Pini Prato, Marcello Carlucci & Vincenzo Jasonni

  2. Anaesthesia and Intensive Care Department, Giannina Gaslini Institute, Genoa, Italy

    Giovanni Montobbio

  3. Neurosurgery Department, Giannina Gaslini Institute, Genoa, Italy

    Armando Cama

  4. Orthopedic Surgery Department, Giannina Gaslini Institute, Genoa, Italy

    Silvio Boero & Maria Beatrice Michelis

  5. Infectious Disease Department, Giannina Gaslini Institute, Genoa, Italy

    Elio Castagnola

  6. Quality Control Office, Giannina Gaslini Institute, Genoa, Italy

    Ubaldo Rosati

  7. Pediatric Surgery Department, G. Gaslini Children’s Hospital, University of Genoa, Largo G. Gaslini 5, 16147, Genoa, Italy

    Edoardo Guida

Authors
  1. Girolamo Mattioli
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  2. Edoardo Guida
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  3. Giovanni Montobbio
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  4. Alessio Pini Prato
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  5. Marcello Carlucci
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  6. Armando Cama
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  7. Silvio Boero
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  8. Maria Beatrice Michelis
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  9. Elio Castagnola
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  10. Ubaldo Rosati
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  11. Vincenzo Jasonni
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Corresponding author

Correspondence to Edoardo Guida.

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Mattioli, G., Guida, E., Montobbio, G. et al. Near-miss events are really missed! Reflections on incident reporting in a department of pediatric surgery. Pediatr Surg Int 28, 405–410 (2012). https://doi.org/10.1007/s00383-011-3047-5

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  • DOI: https://doi.org/10.1007/s00383-011-3047-5

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