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Improving patient safety by detecting obstetric care-related adverse events: application of a new screening guide

  • Maternal-Fetal Medicine
  • Published:
Archives of Gynecology and Obstetrics Aims and scope Submit manuscript

Abstract

Purpose

Determining the magnitude and importance of patient safety-related incidents and the effectiveness of measures to improve patient safety (PS) are high-priority goals in efforts to improve the quality of obstetric care. The aim of this study was to evaluate the usefulness of the MRF1-OBST screening guide in detecting adverse events in women who received obstetric care.

Methods

This retrospective cohort study included 244 women who were hospitalized for delivery. All medical records were reviewed with the MRF1-OBST screening guide to identify adverse events and incidents. This tool is a modified form of the MRF1 screening guide regularly used in epidemiological studies of PS, to which we added items developed specifically for obstetric care. We calculated the positive predictive value and compared the ability of the MRF1 and MRF1-OBST guides to detect incidents related to PS in Obstetrics.

Results

The MRF1-OBST guide did not identify any additional complications during hospitalization or incidents related to PS that were not also identified by the MRF1 guide.

Conclusions

The MRF1-OBST guide did not improve the detection of obstetric AE. The modified version of the guide required more work to use as a screening aid than the original MRF1 instrument. Efforts to improve the detection of incidents related to PS in obstetrics require complementary tools to be developed for information analysis.

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References

  1. World Health Organization (2009) More than words. Conceptual framework for the international classification for patient safety. Technical Report January 2009; WHO. http://www.who.int/patientsafety/implementation/taxonomy/icps_technical_report_en.pdf. Accessed 13 Mar 2013

  2. Kohn L, Corrigan JM, Donaldson MS (eds) (1999) To err is human; building a safer health system. National Academy Press, Washington, DC

    Google Scholar 

  3. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG et al (1991) Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. New Engl J Med 324:70–76

    Article  Google Scholar 

  4. Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ et al (2000) Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 38:261–271

    Article  CAS  PubMed  Google Scholar 

  5. Wilson RM, Runciman WB, Gibberd RW, Harrisson BT, Newby L, Hamilton JD et al (1995) The quality in Australian health care study. Med J Aust 163:458–471

    CAS  PubMed  Google Scholar 

  6. Vincent C, Neale G, Woloshynowych M (2001) Adverse events in British hospitals: preliminary retrospective record review. BMJ 322:517–519

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  7. Schioler T, Lipczak H, Pedersen BL, Mogensen TS, Bech KB, Stockmarr A et al (2001) Incidence of adverse events in hospitals. A retrospective study of medical records. Ugeskr Laeger 163:5370–5378

    CAS  PubMed  Google Scholar 

  8. Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J et al (2004) The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. CMAJ 170:1678–1686

    Article  PubMed Central  PubMed  Google Scholar 

  9. Michel P, Minodier C, Lathelize M, Moty-Monnereau C, Domecq S, Chaleix M et al (2010) Les événements indésirables graves associés aux soins observés dans les établissements de santé Résultats des enquêtes nationales menées en 2009 et 2004. Dossiers Solidarité et Santé 17:1–18

    Google Scholar 

  10. Michel P, Quenon JL, Djihoud A, Tricaud-Vialle S, Sarasqueta AM (2007) French national survey of inpatient adverse events prospectively assessed with ward staff. Qual Saf Health Care 16:369–377

    Article  PubMed Central  PubMed  Google Scholar 

  11. Zegers M, de Bruijne MC, Wagner C, Hoonhout LH, Waaijman R, Smits M et al (2009) Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. Qual Saf Health Care 18:297–302

    Article  CAS  PubMed  Google Scholar 

  12. Soop M, Fryksmark U, Koster M, Haglund B (2009) The incidence of adverse events in Swedish hospitals: a retrospective medical record review study. Int J Qual Health Care 21:285–291

    Article  PubMed Central  PubMed  Google Scholar 

  13. Mendes W, Martins M, Rozenfeld, Travassos C (2009) The assessment of adverse events in hospitals in Brazil. Int J Qual Health Care 21:279–284

    Article  PubMed  Google Scholar 

  14. Aranaz-Andres JM, Aibar-Remón C, Limón-Ramírez R, Amarilla A, Restrepo FR, Urroz O et al (2011) Prevalence of adverse events in the hospitals of five Latin American countries: results of the Iberoamerican study of adverse events (IBEAS). BMJ Qual Saf 20:1043–1051

    Article  CAS  PubMed  Google Scholar 

  15. Wilson RM, Michel P, Olsen S, Gibberd RW El-Assady R, Rasslan O et al (2012) Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital. BMJ 344:e832 doi: 10.1136/bmj.e832. http://www.bmj.com/content/344/bmj.e832. Accessed 02 Apr 2013

  16. Aranaz JM, Aibar C, Vitaller J, Ruiz P, Limón R, Terol E, the ENEAS work group (2008) Incidence of adverse events related to health care in Spain: results of the Spanish National Study of Adverse Events. J Epidemiol Commun Health 62:1022–1029

    Article  Google Scholar 

  17. Gambone JC, Reiter RC (2008) Elements of a successful quality improvement and patient safety program in obstetrics and gynecology. Obstec Gynecol Clin N Am 35:129–145

    Article  Google Scholar 

  18. Guise JM (2007) Anticipating and responding to obstetric emergencies. Best Pract Res Clin Obstet Gynaecol 21:625–638

    Article  PubMed  Google Scholar 

  19. King’s Fund (2008) Safe births: Everybody’s business. An independent inquiry into the safety of maternity services in England. In: Walker I, Grise E (ed) London

  20. Padilla M, Álvarez E, Aranaz J, Jiménez A, García JA (2005) Efectos adversos relacionados con la asistencia sanitaria en ginecología y obstetricia, una revisión crítica. Rev Calidad Asist 20:90–99

    Article  Google Scholar 

  21. Salgado A, Maceira M, López M, Atienza G (2010) Variabilidad del parto en España. Análisis del conjunto mínimo básico de datos al alta hospitalaria. Prog Obstet Ginecol 53:215–222

    Article  Google Scholar 

  22. Alianza Mundial para la Seguridad del Paciente (2008) La investigación en Seguridad del Paciente. Ginebra: Organización Mundial de la Salud. Available at http://www.who.int/patientsafety/information_centre/documents/ps_research_brochure_es.pdf. Accessed 02 Apr 2013

  23. Johnson CE, Handberg E, Dobalian A, Gurol N, Pearson V (2005) Improving perinatal and neonatal patient safety: the AHRQ patient safety indicators. J Perinat Neonatal Nurs 19:15–23

    Article  PubMed  Google Scholar 

  24. McLoughlin V, Millar J, Mattke S, Franca M, Jonsson PM, Somek D, Bates D (2006) Selecting indicators for patient safety at the health system level in OECD countries. Int J Qual Health Care 18:14–20

    Article  PubMed  Google Scholar 

  25. Simpson JR (2005) Failure to rescue in obstetrics. MCN Am J Matern Child Nurs 30:76

    PubMed  Google Scholar 

  26. Nielsen M, Mann S (2008) Team function in obstetrics to reduce errors and improve outcomes. Obstet Gynecol Clin N Am 35:81–95

    Article  Google Scholar 

  27. Institute for healthcare improvement (2006) Perinatal trigger tool. Available at: http://www.ihi.org/knowledge/Pages/Tools/PerinatalTriggerTool.aspx. Accessed 02 Apr 2013

  28. Aranaz JM y el Grupo de Estudio del Proyecto IDEA (2004) Proyecto IDEA: Identificación de efectos adversos. Rev Calidad Asistencial 19:14-8. Available at: http://proyectoidea.com/index2.htm. Accessed 02 Apr 2013

    Google Scholar 

  29. Foster AJ, Fung I, Caughey S, Oppenheimer L, Beach C, Shojania KG, Van Walraven C (2006) Adverse events detected by clinical surveillance on an obstetric service. Obstet Gynecol 108:1073–1083

    Article  Google Scholar 

  30. Florea A, Caughey S, Westland J, Berckmans M, Kennelly C, Beach C et al (2010) The Ottawa hospital quality incident notification system for capturing adverse events in obstetrics. J Obstet Gynaecol Can 32:657–662

    PubMed  Google Scholar 

  31. Pettker CM, Thung SF, Norwitz ER, Buhimshi C, Raab C, Copel J et al (2009) Impact of a comprehensive patient safety strategy on obstetric adverse events. Am J Obstet Gynecol 200:1–8

    Article  Google Scholar 

  32. Pronovost PJ, Goeschel CA, Marsteller JA, Sexton JB, Pham JC, Berenholtz SM (2009) Framework for patient safety research and improvement. Circulation 119:330–337

    Article  PubMed  Google Scholar 

  33. ACOG Committee Opinion No. 447 (2009) Patient safety in obstetrics and gynecology. Obstet Gynecol 114:1424–7

    Google Scholar 

  34. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP et al (2009) A surgical safety checklist to reduce morbidity and mortality in a global population. Safe Surgery Saves Lives Study Group. NEJM 360:491–499

    Article  CAS  PubMed  Google Scholar 

  35. Daniel LK, Simpson EK (2009) Integrating team training strategies into obstetrical emergency simulation training. J Heatlhcare Qual 31:38–42

    Article  Google Scholar 

  36. Mérien EAR, van de Ven J, Mol BW, Houterman S, Oei SG (2010) Multidisciplinary team training in a simulation setting for acute obstetric emergencies. A systematic review. Obstet Gynecol 115:1021–1031

    Article  PubMed  Google Scholar 

  37. Joint Commission (2004) Preventing infant death and injury during delivery. Sentinel Event Alert Issue 30. http://www.jointcommission.org/assets/1/18/SEA_30.PDF. Accessed 02 Apr 2013

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Acknowledgments

We thank the following national experts for their assistance in revising the MRF1-OBST screening guide: Á. Caño-Aguilar, E. Fabre-González, J. Fernández-Parra, A. Herruzo-Nalda, J. Mozas-Moreno, A. Perales-Marin, A. Puertas Prieto and J. Sancho-Miñano. We also thank K. Shashok for translating the original manuscript into English. This work has not been financially supported.

Conflict of interest

The authors declare that they have no conflicts of interest in connection with the research reported in this article.

Author information

Authors and Affiliations

  1. Department of Microbiology, Preventive Medicine and Public Health, University of Zaragoza, Domingo Miral St., 50009, Zaragoza, Spain

    L. Aibar, M. J. Rabanaque & C. Aibar

  2. Department of Obstetrics and Gynecology, Hospital of Santa Barbara, Puertollano, Ciudad Real, Spain

    L. Aibar

  3. Department of Obstetrics and Gynaecology, University of Granada, Granada, Spain

    J. Mozas

  4. Department of Obstetrics and Gynecology, University Hospital Virgen de las Nieves, Granada, Spain

    J. Mozas & A. Puertas

  5. Department of Preventive Medicine, University Hospital Sant Joan d’Alacant, Alicante, Spain

    J. M. Aranaz

  6. Department of Public Health, History of Science and Gynaecology, Miguel Hernández University of Elche, Elche, Alicante, Spain

    J. M. Aranaz

  7. Department of Preventive Medicine, University Hospital Lozano Blesa, Zaragoza, Spain

    C. Aibar

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  1. L. Aibar
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  5. J. M. Aranaz
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Correspondence to L. Aibar.

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Aibar, L., Rabanaque, M.J., Mozas, J. et al. Improving patient safety by detecting obstetric care-related adverse events: application of a new screening guide. Arch Gynecol Obstet 289, 945–952 (2014). https://doi.org/10.1007/s00404-013-3077-4

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  • DOI: https://doi.org/10.1007/s00404-013-3077-4

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