Patient safety incidents in MSF OCG: trends in paediatrics

BACKGROUND

Patient Safety Incident (PSI) reporting is a key component of ensuring good quality of care in MSF projects. Identifying preventable factors that contributed to incidents allows for the development of improvement initiatives. These will mitigate future PSIs in the project and the lessons learnt can be shared more widely.

OBJECTIVES

To highlight data collected about PSIs in 2024 in MSF OCG paediatric and neonatal projects for the purpose of knowledge sharing and advocacy in the wider humanitarian community.

METHODS/STUDY DESIGN

Routinely reported information from OCG field projects is collected and presented in Powerbi. Relevant data was accessed and analysed for the whole of 2024.

RESULTS/EXPECTED RESULTS

In 2024, 160 patients were harmed. 38 (23.8%) were less than 1 year in age, 43 (26.9%) were 1–5 years old, 6 (3.8%) were 6–15 years old.

In children and infants <15 years old (n=87), 51 (63%) occurred on a paediatric ward, 13 (14.9%) on a maternity ward, 9 (10.3%) in inpatient therapeutic feeding centres, 4 (4.6%) in the delivery room, 3 (3.4%) in ER, 3 (3.4%) in a neonatal ward, and 2 (2.2%) in operating theatres. Amongst the 9 never events (preventable PSIs with serious consequences that should never occur) reported, 4 related to limb injuries secondary to tourniquets that were not removed following a venipuncture procedure. The frequency of PSI reporting per mission ranged from 1 to 31, with a mean of 10.7 and median of 6.

CONCLUSIONS/DISCUSSION

Paediatric and neonatal patients were implicated in more than half (54.4%) of the PSIs. Forgotten tourniquets prompted a section-wide awareness strategy and campaign with the aim of eliminating this type of never event in future. Although the frequency of reporting by missions was somewhat proportionate to their admission numbers, there were notable exceptions. This highlights the need to normalise PSI reporting by encouraging an atmosphere of learning and a non-blaming culture.