Near-miss events are really missed! Reflections on incident reporting in a department of pediatric surgery.
OBJECTIVE
The aim of this study was to evaluate the frequency of surgical and organizational events that occurred in the whole Department of Paediatric Surgery at Gaslini Children's Hospital through an incident-reporting system in order to identify the vulnerabilities of this system and improve it.


METHODS
This is a 6-month prospective observational study (1st January-1st July 2010) of all events (including surgical and organizational events, and near misses) that occurred in our department of surgery (pediatric surgery, orthopedics and neurosurgery units).


RESULTS
Over a 6-month study period, 3,635 children were admitted: 1,904 out of 3,635 (52.4%) children underwent a surgical procedure. A total number of 111 adverse events and 4 near misses were recorded in 100 patients. A total of 108 (97.3%) adverse events occurred following a surgical procedure. Of 111 adverse events, 34 (30.6%) required re-intervention. Eighteen of 100 patients (18%) required a re-admission, and 18 of 111 adverse events (16.2%) were classified as organizational. Infection represented the most common event.


CONCLUSIONS
An electronic physician-reported event tracking system should be incorporated into all surgery departments to report more accurately adverse events and near misses. In this system, all definitions must be standardized and near misses should be considered as important as the other events, being a rich source of learning.
Pediatric Surgery Department, Giannina Gaslini Institute, University of Genoa, Genoa, Italy.
Girolamo
G
Mattioli
Edoardo
E
Guida
Giovanni
G
Montobbio
Alessio
A
Pini Prato
Marcello
M
Carlucci
Armando
A
Cama
Silvio
S
Boero
Maria Beatrice
MB
Michelis
Elio
E
Castagnola
Ubaldo
U
Rosati
Vincenzo
V
Jasonni
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D006748:Hospital Departments; D006801:Humans; D007223:Infant; D008297:Male; D010372:Pediatrics; D011446:Prospective Studies; D012308:Risk Management / Q000706:statistics & numerical data*; D013503:Surgery Department, Hospital