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

•The measurement of non-routine events (NRE) is a safety methodology arising from the field of human factors engineering and is meant to detect potential safety alarms well upstream of an adverse event (e.g., NSQIP-P occurrence).•The NRE methodology has never been applied to neonatal surgery, which was our goal. To simplify this pilot study, we applied NRE measurement to G-tube placement in the NICU surgical population.•We found that even in this "simple" operative procedure >80% of cases had an NRE reported by involved clinicians whereas only 19% had a NSQIP-P occurrence reported.•NRE occurrence was not associated with an increased likelihood of an NSQIP-P occurrence, but this methodology does offer novel information that should be considered as we try to increase surgical safety.•Application of this methodology to a broader array of operative procedures is needed.