Mattioli Girolamo, Guida Edoardo, Montobbio Giovanni, Pini Prato Alessio, Carlucci Marcello, Cama Armando, Boero Silvio, Michelis Maria Beatrice, Castagnola Elio, Rosati Ubaldo, Jasonni Vincenzo
Pediatric Surgery Department, Giannina Gaslini Institute, University of Genoa, Genoa, Italy.
Pediatr Surg Int. 2012 Apr;28(4):405-10. doi: 10.1007/s00383-011-3047-5. Epub 2012 Jan 7.
The aim of this study was to evaluate the frequency of surgical and organizational events that occurred in the whole Department of Paediatric Surgery at Gaslini Children's Hospital through an incident-reporting system in order to identify the vulnerabilities of this system and improve it.
This is a 6-month prospective observational study (1st January-1st July 2010) of all events (including surgical and organizational events, and near misses) that occurred in our department of surgery (pediatric surgery, orthopedics and neurosurgery units).
Over a 6-month study period, 3,635 children were admitted: 1,904 out of 3,635 (52.4%) children underwent a surgical procedure. A total number of 111 adverse events and 4 near misses were recorded in 100 patients. A total of 108 (97.3%) adverse events occurred following a surgical procedure. Of 111 adverse events, 34 (30.6%) required re-intervention. Eighteen of 100 patients (18%) required a re-admission, and 18 of 111 adverse events (16.2%) were classified as organizational. Infection represented the most common event.
An electronic physician-reported event tracking system should be incorporated into all surgery departments to report more accurately adverse events and near misses. In this system, all definitions must be standardized and near misses should be considered as important as the other events, being a rich source of learning.
本研究旨在通过事件报告系统评估加斯利尼儿童医院小儿外科整个科室发生的手术和组织事件的频率，以识别该系统的薄弱环节并加以改进。
这是一项为期6个月的前瞻性观察性研究（2010年1月1日至7月1日），涵盖了我们外科科室（小儿外科、骨科和神经外科单元）发生的所有事件（包括手术和组织事件以及险些发生的失误）。
在为期6个月的研究期间，共收治3635名儿童：3635名儿童中有1904名（52.4%）接受了手术。在100名患者中记录了总共111起不良事件和4起险些发生的失误。总共108起（97.3%）不良事件发生在手术后。在111起不良事件中，34起（30.6%）需要再次干预。100名患者中有18名（18%）需要再次入院，111起不良事件中有18起（16.2%）被归类为组织性事件。感染是最常见的事件。
应将电子医生报告的事件跟踪系统纳入所有外科科室，以更准确地报告不良事件和险些发生的失误。在这个系统中，所有定义都必须标准化，险些发生的失误应被视为与其他事件同样重要，因为它是丰富的学习来源。
