The error in neonatal intensive care: a multicenter prospective study

During a nursing conference of the Northeaster Piedmont Neonatal Intensive and Subintensive Neonatal Units the error in pediatrics and neonatology was discussed and a follow-up work was proposed with the aim to understand how many, what type of errors and what kind of adverse event they cause in our clinical practice.

Through an anonymous "detection sheet" we detected the errors made between March 1 and April 30, 2010 in a NICU and 2 Subintensive therapies. The total number of patients was 166 for 2398 days of hospitalization.

The total number of errors was 72, with a error of 0.43/patient. Forty-six patients had experienced at least 1 error (28% of patients) and more than a 16 (10% of our patients). There is a statistically significant correlation between days of hospitalization and the number of errors occurred (r=0.63 Sperman's correlation, P<0.01); 48% and 53% of the errors in the NICU and Subintensive CU were related to medication administration.

The severe damage in the NICU was caused by errors more frequently related to vascular access while the only mistake that led to a serious incident in subintensive CU was determined by a monitoring error. Errors were most frequently attributed to inattention-distraction, less frequently have been attributed to a lack of experience or a state of excessive fatigue. The data of our study were made available to all staff in order to make operators more aware of the importance of working safely.