Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2022 Jul;57(7):1342-1348.
doi: 10.1016/j.jpedsurg.2021.10.019. Epub 2021 Oct 29.

A pilot study to determine the incidence, type, and severity of non-routine events in neonates undergoing gastrostomy tube placement

Daniel J France  1 , Emma Schremp  2 , Evan B Rhodes  2 , Jason Slagle  2 , Sarah Moroz  2 , Peter H Grubb  3 , Leon D Hatch  4 , Matthew Shotwell  5 , Amanda Lorinc  2 , Jamie Robinson  6 , Marlee Crankshaw  7 , Timothy Newman  2 , Matthew B Weinger  2 , Martin L Blakely  8
Affiliations

A pilot study to determine the incidence, type, and severity of non-routine events in neonates undergoing gastrostomy tube placement

Daniel J France et al. J Pediatr Surg. 2022 Jul.

Abstract

Background: Non-routine events (NRE) are defined as any suboptimal occurrences in a process being measured in the opinion of the reporter and comes from the field of human factors engineering. These typically occur well up-stream of an adverse event and NRE measurement has not been applied to the complex context of neonatal surgery. We sought to apply this novel safety event measurement methodology to neonates in the NICU undergoing gastrostomy tube placement.

Methods: A prospective pilot study was conducted between November 2016 and August 2020 in the Level IV NICU and the pediatric operating rooms of an urban academic children's hospital to determine the incidence, severity, impact, and contributory factors of clinician-reported non-routine events (NREs, i.e., deviations from optimal care) and 30-day NSQIP occurrences in neonates receiving a G-tube.

Results: Clinicians reported at least one NRE in 32 of 36 (89%) G-tube cases, averaging 3.0 (Standard deviation: 2.5) NRE reports per case. NSQIP-P review identified 7 cases (19%) with NSQIP-P occurrences and each of these cases had multiple reported NREs. One case in which NREs were not reported was without NSQIP-P occurrences. The odds ratio of having a NSQIP-P occurrence with the presence of an NRE was 0.695 (95% CI 0.06-17.04).

Conclusion: Despite being considered a "simple" operation, >80% of neonatal G-tube placement operations had at least one reported NRE by an operative team member. In this pilot study, NRE occurrence was not significantly associated with the subsequent reporting of an NSQIP-P occurrence. Understanding contributory factors of NREs that occur in neonatal surgery may promote surgical safety efforts and should be evaluated in larger and more diverse populations.

Level of evidence: IV.

Keywords: Gastrostomy; NSQIP occurrences; Neonatal safety; Non-routine events; Perioperative.

PubMed Disclaimer

Conflict of interest statement

Declaration of Competing Interest The authors declare that they have no conflict of interest.

Figures

Figure 1.
Figure 1.
Patient Selection
See this image and copyright information in PMC

References

    1. Weinger MB, Slagle J. Human factors research in anesthesia patient safety: Techniques to elucidate factors affecting clinical task performance and decision making. JAMIA 2002;9(6 (supplement)):S58–S63.
    1. France DJ, Slagle J, Schremp E, Moroz S, Hatch LD, Grubb P, et al. Impact of patient handover structure on neonatal perioperative safety. Journal of perinatology : official journal of the California Perinatal Association 2019;39(3):453–67. - PMC - PubMed
    1. Minnick AF, Donaghey B, Slagle J, Weinger MB. Operating room team members’ views of workload, case difficulty and Non-Routine Events. Journal for healthcare quality : official publication of the National Association for Healthcare Quality 2011. - PubMed
    1. Slagle JM, Anders S, Calderwood C, Weinger MB. Significant physiological disturbances in cases with and without non-routine events: An analysis of videotaped anesthetics. Proc Human Factors Ergon Soc 2009;53:674–8.
    1. Weinger M, Slagle J, Crimin K, Nwosu S, Feinleib J, Schroeder R, et al. Higher pre- and post-case workload ratings by anesthesiologists, surgeons, and OR nurses are associated with Non-Routine Events. Proc Am Soc Anesthesiol Ann Mtg 2011;115:A1728.