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Feasibility and reliability of PRISMA-Medical for specialty-based incident analysis
  1. C Snijders1,2,
  2. T W van der Schaaf3,4,
  3. H Klip5,
  4. R A van Lingen W P F Fetter,
  5. A Molendijk1
  1. 1
    Princess Amalia Department of Paediatrics, Division of Neonatology, Isala Clinics, Zwolle, The Netherlands
  2. 2
    Juliana Children’s Hospital, Haga Hospital, The Hague, The Netherlands
  3. 3
    Division of Patient Safety, Hasselt University, Diepenbeek, Belgium
  4. 4
    Faculty of Technology Management, Eindhoven University of Technology, Eindhoven, The Netherlands
  5. 5
    Research Bureau, Isala Clinics, Zwolle, The Netherlands
  6. 6
    Department of Paediatrics, Division of Neonatology, VU University Medical Center, Amsterdam, The Netherlands
  1. Correspondence to Dr Cathelijne Snijders, Haga Hospital, Location Juliana Children’s Hospital, Sportlaan 600, 2566 MJ The Hague, The Netherlands; c.snijders{at}


Aims and objectives: In this study, the feasibility and reliability of the Prevention Recovery Information System for Monitoring and Analysis (PRISMA)-Medical method for systematic, specialty-based analysis and classification of incidents in the neonatal intensive care unit (NICU) were determined.

Methods: After the introduction of a Neonatology System for Analysis and Feedback on Medical Events (NEOSAFE) in eight tertiary care NICUs and one paediatric surgical ICU, PRISMA-Medical was started to be used to identify root causes of voluntary reported incidents by multidisciplinary unit patient safety committees. Committee members were PRISMA-trained and familiar with the department and its processes. In this study, the results of PRISMA-analysis of incidents reported during the first year are described. At t = 3 months and t = 12 months after introduction, test cases were performed to measure agreement at three levels of root cause classification using PRISMA-Medical. Inter-rater reliability was determined by calculating generalised κ values for each level of classification.

Results: During the study period, 981 out of 1786 eligible incidents (55%) were analysed for underlying root causes. In total, 2313 root causes were identified and classified, giving an average of 2.4 root causes for every incident. Although substantial agreement (κ 0.70–0.81) was reached at the main level of root cause classification of the test cases (discrimination between technical, organisational and human failure) and agreement among the committees at the second level (discrimination between skill-based, rule-based and knowledge-based errors) was acceptable (κ 0.53–0.59), discrimination between rule-based errors (the third level of classification) was more difficult to assess (κ 0.40–0.47).

Conclusion: With some restraints, PRISMA-Medical proves to be both feasible and acceptably reliable to identify and classify multiple causes of medical events in the NICU.

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  • ▸ An appendix A is published online only at

  • Funding CS was funded by the Dutch Association of Medical Specialists.

  • Competing interests None.

  • The NEOSAFE study group

    • Neonatal intensive care units:

      • Academic Medical Center, Amsterdam: JH Kok, MD, PhD; E te Pas, RN

      • Erasmus MC-University Medical Center, Rotterdam: H Pas, RN; C van der Starre MD

      • HagaHospital, The Hague: E Bloemendaal, RN; RH Lopes Cardozo, MD, PhD; AM Molenaar, RN

      • Isala Clinics, Zwolle: A Giezen, RN; RA van Lingen, MD, PhD; HE Maat, RN; A Molendijk, MD, PhD; C Snijders, MD

      • Maastricht University Medical Center: S Lavrijssen, RN; ALM Mulder, MD, PhD

      • Máxima Medical Center, Veldhoven: MJK de Kleine, MD, PhD; AMP Koolen, MD; M Schellekens, RN

      • Radboud University Medical Centre Nijmegen: W Verlaan, RN; S Vrancken, MD

      • VU University Medical Center, Amsterdam: WPF Fetter, MD, PhD; L Schotman, RN; A van der Zwaan, RN

    • Paediatric surgical intensive care unit:

      • Erasmus MC-University Medical Center, Rotterdam: C van der Starre, MD; Y van der Tuijn, RN; D Tibboel, MD, PhD

    • Other departments:

      • Division of Patient Safety, Hasselt University, Diepenbeek, Belgium; Faculty of Technology Management, Eindhoven University of Technology: TW van der Schaaf, PhD

      • Research bureau, Isala Clinics, Zwolle: H Klip, PhD; BJ Kollen, PhD

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