Safety Impact Of Error Reports In Neonatal Intensive Care Not Known

Main Category: Pediatrics / Children's Health
Also Included In: Compliance
Article Date: 25 Mar 2007 - 0:00 PDT

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Voluntary reporting of mistakes made while caring for very sick newborns is more effective than compulsory reporting, says research published ahead of print in the Fetal & Neonatal Edition of the Archives of Disease in Childhood.

But it is unclear what impact error reports have on improving the safety of this very vulnerable group of patients, say the authors.

The findings are based on an extensive trawl of research databases, showing published studies of incident reporting in neonatal intensive care.

When all the information was analysed in detail from the 10 relevant studies, it showed that errors in prescribing or administering drugs were the most common type of reported mistake.

Failure to follow procedures, insufficient attention paid to the task, poor record keeping and/or communication were all to blame.

Most of the studies indicated that voluntary reporting boosted the number of incidents filed compared with compulsory, punitive systems.

The rate of medication error reports was around 13 times higher in voluntary systems. Potentially harmful incidents featured in almost every study.

Changes were made to processes following the reports, but the guaranteed anonymity of voluntary systems prevented further detailed analysis of the causes of the mistakes.

And complex errors, such as failure to prioritise clinical tasks appropriately or carry out assessments, which could equally affect the outcome of care, are often not reported, because they are difficult to measure, say the authors.

"Assessing the impact of preventive strategies on patient safety remains a challenge," they comment. "Although voluntary reporting systems increase the number of reports, under reporting is still likely," they say.

And it is still unclear whether patient safety is improved on the basis of the available evidence, they conclude.

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