Introduction One in eight babies receive neonatal care in the United Kingdom. Neonates are vulnerable to patient safety incidents due to their immature physiology and requirement for highly intensive care. Patient safety is predicated on the ability to learn from unsafe care. This study is the largest analysis of neonatal patient safety incidents reports from England and Wales to identify the most frequent and most harmful incidents on neonatal units.
Methods The National Reporting and Learning System (NRLS) database receives incident reports from all NHS organisations in England and Wales. All reports submitted from neonatal units between 1 April 2005 and 29 December 2015 were analysed. Exploratory descriptive analysis identified relationships between structured data variables in NRLS, including: type of incident, reported reason for medication error, drug name, and severity of harm outcome. The most frequent or harmful relationships were discussed by a multidisciplinary team with patient safety expertise and knowledge of national guidance.
Results A 2.2-fold increase in reporting exists from 2006 (n=5,172) to 2015 (n=16,466). Of 1 25 832 reports, over one fifth (n=28,796, 22.9%) described harmful outcomes. Errors during delivery of a treatment or procedure were most frequent (23.3%, n=6,703) with 24.4% (n=1,636/6,703) describing extravasation injury. Medication errors accounted for one fifth of reports (21.9%, n=27,522/125,832) of which 13% (n=3,570/27,520) resulted in harm. Most frequently an omission of a medication or ingredient (21.3%, n=784/3,678), wrong or unclear dose or strength (18.5%, n=679/3,678) and wrong frequency (14.5%, n=534/3,678) were reported. Gentamicin (17.4%, n=3,196/18,395), parenteral nutrition (7.07%, n=1,301/18,395) and morphine (6%, n=1,112/18,395) featured most often. Severe harm outcomes resulted from incidents involving morphine (n=5), parenteral nutrition (n=2) and calcium-related medication (n=2).
Conclusion One in five reported safety incidents resulted in iatrogenic harm to a neonate. A quarter of incidents occurred during the delivery of a treatment or procedure. We have identified the most frequent and most harmful reported patient safety incidents involving neonates over a 10 year period. Further in-depth characterisation of reports is required to inform the design of preventive interventions, particularly incidents that persist despite existing patient safety interventions used in the past decade.
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