Iatrogenesis in Neonatal Intensive Care Units: Observational, Prospective, Cohort study

Abstract

SUMMARY I atrogenic events incur financial, medicolegal, and human costs, and this source of patient injury has been increasingly recognized as an important problem in all hospitals. Hospitalized neonates, many of whom require treatment for conditions related to premature birth, are frequently exposed to invasive therapies and, thus, are particularly vulnerable to IEs. The aim of this study was to define the epidemiological characteristics (incidence, severity, preventability, and risk factors) of iatrogenesis in neonates admitted to hospital in a high-risk neonatal center. We conducted this observational prospective cohort study in the NICU of Children’s Hospital, Ain Shams University between February 2015 and July 2015. It was carried on 88 neonates. All the mothers and newborns were subjected to detailed medical history, thorough clinical examination and laboratory. In our study, we found that 87.5% of the examined neonates experienced iatrogenic events. 5 of the neonates had single event representing 6.5% of all affected neonates while the rest has multiple IEs. 475 iatrogenic events were recorded in 77 out of 88 neonates who were admitted. We considered 413 were preventable, representing 87%. 188 were categorized as medical iatrogenic events representing 54.5%. Life-threatening IEs represent 8.2% of all IEs, significant IEs represent 29.3% of all IEs, harmful IEs represent 25.7% of all IEs, the intercepted IEs represent 14.3% of all IEs and the corrected IEs represent 66.7% of all IEs. It could be that medication errors are easier to intercept. The most common cause of life threatening IEs was ventilator-related iatrogenesis. In our study, neonates with LBW (<2.5 Kg), duration of hospitalization > 7 days, and those referred from another NICU were more susceptible to iatrogenic events Our study showed a high incidence of cutaneous injury representing 15.3% of total IEs. They were the most preventable event 17.1% of total preventable IEs, followed by medication-related iatrogenesis 13.47% of total preventable IEs. The most harmful IEs were hospital acquired infections representing 26.22 % of total harmful IEs, followed by respiratory events including both ventilator and N-CPAP related IEs representing 18.85%. The most common ventilator-related IE was ETT obstruction (83.8 valid percent). In the view of ETT blockage, it depends on physician and nursing staff respiratory care, manufacturing defects in ETT and patients’ characteristics. No neonate experienced nasal septum injury but CPAP related skin laceration (48.4 valid percent) and 3 neonates experienced. In the view of GIT-related IEs, 11% IEs were life threatening out of total life threatening events. No one experienced NGT related perforation,4 experienced NJT-related perforation. No one experienced parenteral nutrition-associated cholestasis. In additional assessment of IEs, we examined phototherapy-related iaterogenesis in the present study where 6 out of 9 phototherapy-related IEs were correctable events (66.6%) and no life threatening of phototherapy-related events had been recorded. Detailed description of phototherapy-related IEs showed that one experienced phototherapy-induced skin rash, 3 experienced phototherapy-induced hyperthermia. Upon studying equipment failure-related iatrogenic events, 21 neonates experienced iatrogenic events related to equipment failure (23.8%), Only one harmful and one life threatening equipment failure-related IEs were recorded. As for environmental IEs 36 out of 46 IEs were preventable including 8 medical events and 4 IEs were life threatening (8.6%). On an attempt to evaluate the incidence of hospital acquired infection in the current analysis, we observed that out of the 75 neonates admitted for > 48 hours in our NICU, (77.3%) developed hospital acquired infection. 46 out of the hospital acquired infections were preventable (79.3%), 58.6 % of the hospital acquired infections were significant, 13.7% were life threatening events and 67.2% were corrected; this was the most correctable event in relation to the other events. As regards the pathogens responsible for nosocomial infections in our NICU, coagulase negative Staphylococci was isolated in 46.7% of all neonates admitted for more than 48 hours. On the attempt to assess medication-related iatrogenic events, we recorded 64 medication-related iatrogenesis happened among the examined neonates (72.7%) and only 1 event was life threatening. We found that most medication errors occurred during administration stage in 72.72% of all neonates and one was subjected to wrong route of administration (1.1 valid percent). Moreover, Error in the drug ordering stage was the second most common medication errors representing 71.5% of all neonates and iatrogenesis related to the drug itself representing 30.6% of all IEs In the present analysis, CVC-related IEs represents 9.26% of all IEs. in 44 out of 48 neonates who performed CVC insertion 91.7 %, 95.45% of them were preventable, 6 events were life threatening and no one experienced pericardial effusion. Concerning cutaneous-related IEs represents 15.3% out of all IEs. Significant events represent 16.4% out of total cutaneous IEs, 10.9% were harmful events and it was the most correctable event representing 69.8%. No life threatening event had occurred.