Systematic analysis of adverse incident reports revealed the need for improvements in the neonatal unit.

ABSTRACT

AIM: The aims were to characterise adverse incident reports and recommendations to avoid the reoccurrence of adverse incidents and detect a possible increase in incidents outside of office hours and on vacation season. METHODS: Analysis of adverse incidents reported at the neonatal intensive care unit of Tampere University Hospital in Finland between 2013 and 2020. RESULTS: Analysis of 925 fully processed adverse incident reports revealed that 36.3% of the reports were related to medication, fluid management and blood products, and 34.8% of these were administering errors. Nurses reported 828 (89.5%) adverse incidents and physicians reported 37 (4.0%). Near misses constituted 35.3% of nurses' and 21.6% of physicians' reports. There were significantly more adverse incident reports on day shifts, on Thursdays and, Saturdays and in June, November and December than at other times. The interventions recommended were to inform the staff or other parties after 673 (72.7%) reports and to recommend improvements after 56 (6.0%) reports. CONCLUSION: Analysis of adverse incident reports can reveal the need for improvements in existing protocols in the neonatal intensive care unit.