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NICU patient SAFETY - Error reporting system


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Dear Colleagues,

I want to know what type of system do you have in place to report errors, adverse events, near misses in the NICU.

How do you ensure confidentiality of these reports so that more people come forward with reports? I am not referring to parents' complaints but to self-reporting by health care givers.

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Locally, we have an electronic report system on our intraweb (the same for the whole Karolinska university hospital). Anyone in the staff can report "local incidents" in our units and a group analyse and classify all reports according to pre-defined criteria.

All kinds of events can be reported here: poor cleaning, drug doses missed, difficulties to have emergency x-rays done within a reasonable time, etc-etc.

The event report together with the analysis is reported back on a monthly basis, to our staff AND to the heads of all departments involved in the report. For example, if the report is about an issue with emergency x-rays, the head of the radiology department gets a copy of the report+analysis.

The idea behind is to have a control system with a feedback mechanism, resulting in an improved quality of care.

This report system is confidential "externally", although the group knows who's reporting what.

For serious adverse events, the department can report to the National Board of Health and Welfare, which then decides whether an audit should be done with independent experts.

If parents feel that serious mistakes have been done, they can also report to the National Board of Health, and have "their case" scrutinized.

These two latter kinds of reports are quite unusual.

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