Identifying neonatal adverse events in preterm and term infants using a paediatric trigger tool

• Published in: Acta Paediatrica Vol. 112; no. 8; pp. 1670 - 1682
• Main Authors: Dillner, Pernilla, Unbeck, Maria, Norman, Mikael, Nydert, Per, Härenstam, Karin Pukk, Lindemalm, Synnöve, Wackernagel, Dirk, Förberg, Ulrika
• Format: Journal Article
• Language: English
• Published: Norway Wiley Subscription Services, Inc 01.08.2023
• Subjects: Adverse event; Adverse events; Birth weight; Blood vessels; Child; Hospitalization; Humans; Infant; Infant, Newborn; Infant, Premature; Infants; Inpatients; Medicin och hälsovetenskap; Neonatal care; Neonates; Patient Safety; Patients; Retrospective record review; Retrospective Studies; Trigger tool; adverse event; patient safety; trigger tool; neonatal care; retrospective record review
• ISSN: 0803-5253; 1651-2227; 1651-2227
• DOI: 10.1111/apa.16814

Aim To explore the incidence and characteristics of inpatient neonatal adverse events in a Swedish setting. Methods A retrospective record review, using a trigger tool, performed by registered nurses and a neonatologist, at a University Hospital. The identified adverse events were categorised by, for example, preventability, severity and time of occurrence. Results A random selection of 150 admissions representing 3531 patient days were reviewed (mean [SD] birthweight 2620 [1120]g). Three hundred and sixty adverse events were identified in 78 (52.0%) infants, and 305 (84.7%) of these were assessed as being preventable. The overall adverse event rate was 240 per 100 admissions and 102.0 per 1000 patient days. Preterm infants had a higher rate than term infants (353 versus 79 per 100 admissions, p = 0.001); however, with regard to the length of stay, the rates were similar. Most adverse events were temporary and less severe (n = 338/360, 93.9%) and the most common type involved harm to skin, tissue or blood vessels (n = 163/360, 45.3%). Forty percent (n = 145) of adverse events occurred within the first week of admission. Conclusion Adverse events were common in neonatal care, and many occurred during the first days of treatment. Characterisation of adverse events may provide focus areas for improvements in patient safety.