title: Provisional unicentric experience with an electronic incident reporting form in pediatric anesthesia.
abstract: OBJECTIVE
  To present and compare with literature our experience with an electronic anesthesia-related incident reporting form as a quality control measure at Gaslini Children's Hospital over a 19-month period.
  
  
  METHODS
  All events that occurred between March 2009 and September 2010 were recorded. We adopted an electronic reporting form included in the online recording process of every anesthetic procedure. Events were divided into near misses and adverse events. Adverse events were further divided into incidents, minor events, and major events. Patients were divided into three age-groups: <1, between 1 and 3, and >3 years.
  
  
  RESULTS
  A total of 12,850 anesthetics were performed. Eight (0.06%) near misses and 108 (0.8%) adverse events were reported. Adverse events occurred more frequently in infants. Of 108 events, 35 (32.4%), 61 (56.5%), and 12 (11.1%) were classified as incidents, minor, and major events, respectively. Of all the adverse events, 66 (61%) were respiratory, 27 (25%) organizational, six (5%) drug-related, four (4%) cardiocirculatory, and five (5%) miscellaneous.
  
  
  CONCLUSIONS
  Infants were at the highest risk to experience adverse events. Although experimental electronic incident reporting proved to be feasible, there is reason to suspect that there was underreporting of near misses. Overreporting of near miss events may be enhanced by easier and more straightforward reporting forms as well as by better education for anesthetic providers about the importance of recognizing and reporting near misses.
authors.affiliation: Department of Anaesthesia and Intensive Care, Giannina Gaslini Institute, Genoa, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Montobbio
authors.forename: Alessio
authors.initials: A
authors.lastname: Pini-Prato
authors.forename: Edoardo
authors.initials: E
authors.lastname: Guida
authors.forename: Nicola
authors.initials: N
authors.lastname: Disma
authors.forename: Leila
authors.initials: L
authors.lastname: Mameli
authors.forename: Stefano
authors.initials: S
authors.lastname: Avanzini
authors.forename: Roberto
authors.initials: R
authors.lastname: Scali
authors.forename: Pietro
authors.initials: P
authors.lastname: Tuo
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Jasonni
authors.forename: Girolamo
authors.initials: G
authors.lastname: Mattioli
mesh_terms: D000293:Adolescent; D000328:Adult; D017677:Age Distribution; D000758:Anesthesia / Q000009:adverse effects*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D011446:Prospective Studies; D012308:Risk Management / Q000706:statistics & numerical data*; D055815:Young Adult