• Marco Daverio, Giuliana Fino, Brugnaro Luca, Cristina Zaggia, Andrea Pettenazzo, Antonella Parpaiola, Paola Lago, and Angela Amigoni.
• Department of Woman's and Child's Health, Pediatric Residency Program, University of Padova, Padova, Italy.
• Paediatr Anaesth. 2015 Dec 1; 25 (12): 1227-34.

BackgroundErrors in are estimated to occur with an incidence of 3.7-16.6% in hospitalized patients. The application of systems for detection of adverse events is becoming a widespread reality in healthcare. Incident reporting (IR) and failure mode and effective analysis (FMEA) are strategies widely used to detect errors, but no studies have combined them in the setting of a pediatric intensive care unit (PICU).AimThe aim of our study was to describe the trend of IR in a PICU and evaluate the effect of FMEA application on the number and severity of the errors detected.MethodsWith this prospective observational study, we evaluated the frequency IR documented in standard IR forms completed from January 2009 to December 2012 in the PICU of Woman's and Child's Health Department of Padova. On the basis of their severity, errors were classified as: without outcome (55%), with minor outcome (16%), with moderate outcome (10%), and with major outcome (3%); 16% of reported incidents were 'near misses'. We compared the data before and after the introduction of FMEA.ResultsSixty-nine errors were registered, 59 (86%) concerning drug therapy (83% during prescription). Compared to 2009-2010, in 2011-2012, we noted an increase of reported errors (43 vs 26) with a reduction of their severity (21% vs 8% 'near misses' and 65% vs 38% errors with no outcome).ConclusionWith the introduction of FMEA, we obtained an increased awareness in error reporting. Application of these systems will improve the quality of healthcare services.© 2015 John Wiley & Sons Ltd.

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