Effect of in-hospital training on medical errors made by teams during neonatal resuscitation

Int J Risk Saf Med. 2024 May 15. doi: 10.3233/JRS-230056. Online ahead of print.

Abstract

Background: Neonatal resuscitation is one of the most critical and risky events that requires a high level of individual skill and team performance.

Objective: To evaluate the effect of training of resuscitation teams on the frequency and type of medical errors (ME) that result from neonatal resuscitation.

Methods: A prospective observational study was performed using a checklist to detect ME related to neonatal resuscitation.

Results: The rate of ME was 24.82%. There was a significant reduction in the percentage of errors from 17.28% in pre- pre-training phase to 7.54% in post post-training phase. Near miss MEs (98.77%) were significantly higher than adverse events. The active errors were significantly higher than latent errors, P < 0.001, and decreased from 39.19% during pre-training to 19.64% in the post-training phase. The commission ME s were significantly higher than the omission, P < 0.001. The latent errors percentage was 41.17% of the total errors and were not significantly reduced after training.

Conclusion: Training sessions reduced ME that occurred during resuscitation, however careful distinguishing and recognizing the type of MEs is important to plan for further reduction of errors. Special attention to latent errors is imperative as it needs a specific approach rather than just training.

Keywords: Medication errors; debriefing; neonatal resuscitation; patient safety; training.