[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.


OBJECTIVE
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.


METHODS
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.


RESULTS
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.


CONCLUSIONS
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.
Festini
Filippo
F
Università di Firenze, Dipartimento di pediatria, Sezione di Scienze infermieristiche e delle Professioni sanitarie.
Bisogni
Sofia
S
Galici
Valeria
V
Neri
Stella
S