Iatrogenic Events Reported in 30% of Hospitalized Neonates

Iatrogenic events occur quite frequently in the care of high-risk neonates, according to a study from France that found 116 of 388 patients admitted to a neonatal unit experienced an event.

Twenty-nine percent of the 267 events were considered severe, and 34% were judged to have been preventable.

An event was defined as something that potentially compromised a patient's safety. A severe event was defined as any event that resulted in disability, death, or an extended hospital stay.

"Our study has shown that a substantial proportion of neonates admitted to hospital had iatrogenic events, a significant proportion of which were preventable," wrote Dr. Isabelle Ligi of the division of neonatology of La Conception Hospital in Marseille, and her colleagues (Lancet 2008;371:404–10).

The study showed an incidence rate of 26 events per 1,000 patient days. Fifty-six of the 116 patients who experienced an event experienced more than one. Two patients died following an iatrogenic event, although in neither case was that event considered preventable.

The study was a test of an anonymous, iatrogenic-event reporting system designed by the hospital's neonatology division, and it considered the events reported among all admissions between Jan. 1, 2005, and Sept. 1, 2005.

The study findings suggest that iatrogenic events in hospitalized neonates may be less often preventable than those that occur to adults and older children, Dr. Ligi and her associates said. It is estimated that 40%–60% of iatrogenic adverse events in adults and children are preventable. In this study, only 34% were judged preventable, and only 21 of 78 events (27%) that were considered severe were judged preventable.

The investigators also reported that the major risk factors for an event included low gestational age and low birth weight, use of a central line, and mechanical ventilation.

Cutaneous injuries and nosocomial infections were the most common events recorded; nosocomial infections and respiratory iatrogenic events were the most severe, Dr. Ligi and her associates said.

Out of a total of 267 events recorded, 94 (35%) were cutaneous events and 62 (23%) were nosocomial infections. Forty-nine (79%) of the nosocomial infections were considered severe and nine of the 26 (35%) respiratory events were considered severe. Drug-related (34) events were common, but usually minor.

In a commentary published with the study, Dr. Gitte Larsen and Dr. Howard Parker said the study shows how efforts to reduce medical errors and other iatrogenic events need to be implemented locally (Lancet 2008;371:364–5).

Individual hospitals need to know what their specific errors are, and strategies developed nationally to reduce errors are likely to be inadequate, said Dr. Larsen and Dr. Parker of Primary Children's Medical Center, Salt Lake City, Utah.

Iatrogenic events occur quite frequently in the care of high-risk neonates, according to a study from France that found 116 of 388 patients admitted to a neonatal unit experienced an event.

Twenty-nine percent of the 267 events were considered severe, and 34% were judged to have been preventable.

An event was defined as something that potentially compromised a patient's safety. A severe event was defined as any event that resulted in disability, death, or an extended hospital stay.

"Our study has shown that a substantial proportion of neonates admitted to hospital had iatrogenic events, a significant proportion of which were preventable," wrote Dr. Isabelle Ligi of the division of neonatology of La Conception Hospital in Marseille, and her colleagues (Lancet 2008;371:404–10).

The study showed an incidence rate of 26 events per 1,000 patient days. Fifty-six of the 116 patients who experienced an event experienced more than one. Two patients died following an iatrogenic event, although in neither case was that event considered preventable.

The study was a test of an anonymous, iatrogenic-event reporting system designed by the hospital's neonatology division, and it considered the events reported among all admissions between Jan. 1, 2005, and Sept. 1, 2005.

The study findings suggest that iatrogenic events in hospitalized neonates may be less often preventable than those that occur to adults and older children, Dr. Ligi and her associates said. It is estimated that 40%–60% of iatrogenic adverse events in adults and children are preventable. In this study, only 34% were judged preventable, and only 21 of 78 events (27%) that were considered severe were judged preventable.

The investigators also reported that the major risk factors for an event included low gestational age and low birth weight, use of a central line, and mechanical ventilation.

Cutaneous injuries and nosocomial infections were the most common events recorded; nosocomial infections and respiratory iatrogenic events were the most severe, Dr. Ligi and her associates said.

Out of a total of 267 events recorded, 94 (35%) were cutaneous events and 62 (23%) were nosocomial infections. Forty-nine (79%) of the nosocomial infections were considered severe and nine of the 26 (35%) respiratory events were considered severe. Drug-related (34) events were common, but usually minor.

In a commentary published with the study, Dr. Gitte Larsen and Dr. Howard Parker said the study shows how efforts to reduce medical errors and other iatrogenic events need to be implemented locally (Lancet 2008;371:364–5).

Individual hospitals need to know what their specific errors are, and strategies developed nationally to reduce errors are likely to be inadequate, said Dr. Larsen and Dr. Parker of Primary Children's Medical Center, Salt Lake City, Utah.

Iatrogenic events occur quite frequently in the care of high-risk neonates, according to a study from France that found 116 of 388 patients admitted to a neonatal unit experienced an event.

Twenty-nine percent of the 267 events were considered severe, and 34% were judged to have been preventable.

An event was defined as something that potentially compromised a patient's safety. A severe event was defined as any event that resulted in disability, death, or an extended hospital stay.

"Our study has shown that a substantial proportion of neonates admitted to hospital had iatrogenic events, a significant proportion of which were preventable," wrote Dr. Isabelle Ligi of the division of neonatology of La Conception Hospital in Marseille, and her colleagues (Lancet 2008;371:404–10).

The study showed an incidence rate of 26 events per 1,000 patient days. Fifty-six of the 116 patients who experienced an event experienced more than one. Two patients died following an iatrogenic event, although in neither case was that event considered preventable.

The study was a test of an anonymous, iatrogenic-event reporting system designed by the hospital's neonatology division, and it considered the events reported among all admissions between Jan. 1, 2005, and Sept. 1, 2005.

The study findings suggest that iatrogenic events in hospitalized neonates may be less often preventable than those that occur to adults and older children, Dr. Ligi and her associates said. It is estimated that 40%–60% of iatrogenic adverse events in adults and children are preventable. In this study, only 34% were judged preventable, and only 21 of 78 events (27%) that were considered severe were judged preventable.

The investigators also reported that the major risk factors for an event included low gestational age and low birth weight, use of a central line, and mechanical ventilation.

Cutaneous injuries and nosocomial infections were the most common events recorded; nosocomial infections and respiratory iatrogenic events were the most severe, Dr. Ligi and her associates said.

Out of a total of 267 events recorded, 94 (35%) were cutaneous events and 62 (23%) were nosocomial infections. Forty-nine (79%) of the nosocomial infections were considered severe and nine of the 26 (35%) respiratory events were considered severe. Drug-related (34) events were common, but usually minor.

In a commentary published with the study, Dr. Gitte Larsen and Dr. Howard Parker said the study shows how efforts to reduce medical errors and other iatrogenic events need to be implemented locally (Lancet 2008;371:364–5).

Individual hospitals need to know what their specific errors are, and strategies developed nationally to reduce errors are likely to be inadequate, said Dr. Larsen and Dr. Parker of Primary Children's Medical Center, Salt Lake City, Utah.