[Voluntary incident reporting by nurses in a pediatric hospital: a pilot study]

In recent years Voluntary Incident Reporting (VIR) has spread as a tool to monitor and prevent adverse events in healthcare (AE). In Italy, experiences of VIR are limited.

The goals of this pilot study were to test the feasibility of a VIR system in a population of nurses of a Pediatric Hospital and to make a preliminary survey of situations of risk for patients' safety, to plan corrective actions.

Nurses of 3 wards were asked to report AEs with or without harm for patient, near misses and unsafe behaviours or situations at risk for generating AEs. Results were cumulatively reported to participating nurses during ward's meetings and possible corrective interventions were discussed.

The study was carried out from April to August 2006. Eighty-seven nurses participated. Forty-eight reports were made (one third signed, two thirds anonymous). Twenty reports (41.6%) regarded unsafe behaviours or situations at risk for AEs, 11 near misses, 15 AEs without patient harm and 2 AEs with harm. Twenty-three reports involved patients. Reports regarded mainly therapy (62.5%), care delivery (14.5%), equipment (8.3%), clinical documentation (6.3%). 40% of all AEs and near misses were reported to happen during the first or the last hour of the shift. AEs most frequently reported were: missing administration of treatments, administration of a wrong drug or of a wrong dose. "Look-alike" drugs and incomplete or illegible prescriptions.

Our pilot study confirms that nurses are generally willing to get involved in VIR systems. It also suggests that to succeed VIR systems have to ensure that reporters remain anonymous and non-prosecutable.