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Please use this identifier to cite or link to this item: http://hdl.handle.net/1942/11831

Title: Incidents associated with mechanical ventilation and intravascular catheters in neonatal intensive care: exploration of the causes, severity and methods for prevention
Authors: Snijders, Cathelijne
van Lingen, Richard A.
VAN DER SCHAAF, Tjerk
Fetter, Willem P. F.
Molendijk, Harry A.
Issue Date: 2011
Publisher: B M J PUBLISHING GROUP
Citation: ARCHIVES OF DISEASE IN CHILDHOOD-FETAL AND NEONATAL EDITION, 96(2). p. F121-F126
Abstract: Objectives To systematically investigate the causes and severity of incidents with mechanical ventilation and intravascular catheters in neonatal intensive care units (NICUs) in the Netherlands, in order to develop effective strategies to prevent such incidents in the future. Design Prospective multicentre survey. Methods Inclusion criteria were: incidents with mechanical ventilation and intravascular catheters reported to a voluntary, non-punitive, incident-reporting system which had been systematically analysed using the Prevention Recovery Information System for Monitoring and Analysis (PRISMA)-Medical method. The type, severity and causes of incidents reported from 1 July 2005 to 31 March 2007 are described. Local interventions performed as a result of systematic analysis of incidents are also described. Results 533 of 1306 (41%) reported incidents with mechanical ventilation and intravascular catheters (n=339/856 and n=194/450, respectively) had been PRISMA analysed and were included in the study. Four incidents resulted in severe harm, 18 in moderate harm and 222 in minor harm. Tube-related incidents accounted for the greatest proportion of harm. 1233 root causes were identified, with most being classified as human error (55%). Of the remaining failures, 20% were organisational, 16% technical, 6% patient-related and 4% unclassifiable. The majority of failures were rule-based errors. Conclusion Incidents with mechanical ventilation and intravascular catheters occur regularly in NICUs, and frequently harm patients. Multicentre, systematic analysis increases our knowledge of these events. Continuous training and education of all NICU personnel is required, together with preventive strategies aimed at the whole system - including the technical and organisational environment - rather than at human failure alone.
Notes: [Snijders, Cathelijne; van Lingen, Richard A.; Molendijk, Harry A.] Isala Clin, Div Neonatol, Princess Amalia Dept Paediat, Zwolle, Netherlands. [Snijders, Cathelijne] Haga Hosp, Juliana Childrens Hosp, The Hague, Netherlands. [van der Schaaf, Tjerk W.] Hasselt Univ, Patient Safety Grp, Dept Business Econ, Diepenbeek, Belgium. [Fetter, Willem P. F.] Vrije Univ Amsterdam Med Ctr, Div Neonatol, Dept Paediat, Amsterdam, Netherlands. c.snijders@grimbergen.net
URI: http://hdl.handle.net/1942/11831
DOI: 10.1136/adc.2009.178871
ISI #: 000287986800010
ISSN: 1359-2998
Category: A1
Type: Journal Contribution
Validation: ecoom, 2012
Appears in Collections: Research publications

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