• E Bellora and M Falzoni.
• Maggiore della Carità University Hospital Novara, Italy - aj.spunky@hotmail.it.
• Minerva Pediatr. 2013 Dec 1;65(6):617-30.

AimThe aim of this prospective cohort study was to conduct a proactive analysis of procedural errors as revealed after implementation of a surgical safety checklist in the pediatric operating room of the Maggiore della Carità University Hospital, Novara. A further aim was to determine the effect the checklist had on the reduction, prevention, and protection against clinical risk in this setting.MethodsA "Checklist for Patient Safety in the Pediatric Operating Room" was derived from documentation in the international literature and implemented in June 2011. All data were collected by a single observer.ResultsIn all, 61 checklists were compiled. Analysis revealed 189 errors (absolute frequency), with the highest error incidence (59.78%) recorded for the sign-out phase (percentage cumulative frequency). Two categories of events were distinguished (surgical and orthopedic) and compared. The absolute frequency of near-miss events (n=168) and adverse events (n=21) was then broken down into the five phases of checklist compilation. The percentage cumulative frequency of near-miss was 88.89% and that of adverse events was 11.11%.ConclusionSafety checklist implementation led to reduction, prevention and protection against adverse events with patient injury in 88.89% of cases. The error incidence in this pediatric operating room was lower than the average rates published in the literature.

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