Samenvatting
Dit artikel bevat een terugblik op de NEOSAFE-studie, een prospectieve multicenterstudie waarbij verschillende aspecten van veiligheidscultuur, incidenten melden en incidentanalyse onderzocht werden. Een decentraal meldings- en analysesysteem voor het vrijwillig en niet-bestraffend melden van incidenten (NEOSAFE) werd geïntroduceerd in acht neonatale intensive-care-units (NICU’s) in Nederland. Een incident werd gedefinieerd als elke onbedoelde gebeurtenis in het zorgproces die tot schade aan de patiënt heeft geleid of kan leiden. Door de vele meldingen en decentrale analyse werden procesafwijkingen op de NICU beter zichtbaar. Het hoofddoel van een veiligheidsmanagementsysteem, namelijk preventie van schade aan patiënten in de NICU ten gevolge van incidenten, lijkt met de introductie van NEOSAFE iets dichterbij gekomen.
Summary
This manuscript looks back on the NEOSAFE study, a prospective multicenter survey, which analysed a number of aspects of safety culture, incident reporting and incident analysis. A voluntary, non-punitive incident reporting system (NEOSAFE) was introduced in eight level III Neonatal Intensive Care Units (NICUs) in The Netherlands. An incident was defined as any unintended event which (could have) reduced the safety margin for the patient. After introduction of the voluntary, non-punitive reporting system, the impact of process deviations in the NICU became more visible through the great number of incident reports and subsequent analysis. Future studies should focus on the development of powerful interventions to prevent adverse events in the NICU.
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Dr. Cathelijne Snijders, kinderarts. Medisch Centrum Leeuwarden.
Correspondentieadres: Dr. C. Snijders, Medisch Centrum Leeuwarden, H. Dunantweg 2, 8935 AD Leeuwarden, cathelijne.snijders@znb.nl.
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Snijders, C. Patiëntveiligheid op de neonatale intensive-care-unit. TIJDSCHR. KINDERGENEESKUNDE 82, 160–165 (2014). https://doi.org/10.1007/s12456-014-0034-5
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DOI: https://doi.org/10.1007/s12456-014-0034-5