Learning from mistakes: analyzing incidents in a neonatal care unit

• Main Authors: Louíse Viecili Hoffmeister, Gisela Maria Schebella Souto de Moura, Ana Paula Morais de Carvalho Macedo
• Format: Article
• Language: English
• Published: Universidade de São Paulo 2019-02-01
• Series: Revista Latino-Americana de Enfermagem
• Subjects: Patient Safety; Medical Errors; Neonatology; Nursing Care; Medication Errors; Quality of Health Care
• Online Access: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692019000100314&lng=en&tlng=en

ABSTRACT Objective: to analyze incidents reported in a neonatal care unit. Method: a quantitative, cross-sectional and retrospective study with a sample of 34 newborns. Data were collected through a structured form, composed of two parts: sociodemographic/clinical characteristics of the newborns, and characteristics of the reported incidents. Data were collected from the institution’s computer system, in a period corresponding to 13 months, and analyzed by means of descriptive statistics. Results: the majority of the newborns were preterm (70.6%), male (52.9%) and born through caesarean section (76.5%). During the study period, 54 incidents were reported, totaling a frequency of 1.6 incident per newborn. It was found that 61.1% of incidents were related to medicines, 14.8% to accidental loss of tracheal tube and 9.3% to catheter obstruction. Conclusion: analysis of the reported incidents has shown that most incidents refer to the drug process. Information about the incidents can increase the perception of health professionals regarding the impact of their actions.