Preventable Adverse Events in Obstetrics—Systemic Assessment of Their Incidence and Linked Risk Factors
Abstract
:1. Introduction
2. Materials and Methods
3. Results
3.1. Evaluation of the pAE Categories
3.2. Risk Factors as Triggers of pAE
3.3. Cross-Tabulation of Risk Factors with pAE
4. Discussion
4.1. Operationalization of Preventability
4.2. Systematic Recording of Serious Incidents
4.3. Evaluation of Adverse Events from Clinical Risk Management
4.4. Risk Factor Analysis
4.5. Care Management Problems
4.6. Prospective Analysis
4.7. Resilient Health Care
4.8. Recommendations for Error Prevention
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Category | Adverse Event (AE) | Definition/Further Operationalization |
---|---|---|
Maternal | Allergy | |
Anemia | Hb < 8 mg/dL | |
Postpartum length of stay | >3 days after vaginal birth | |
Blood loss | >1000 mL | |
Diabetic ketoacidosis | ||
Disseminated intravascular coagulation (DIC) | ||
Eclampsia | ||
Electrolyte derailment | ||
Fever | >38.5 °C | |
Labor arrest | Cesarean section necessary | |
Hypertension | >180/110 mmHg | |
Hypotension | <90/60 mmHg | |
Infection | Treatment with antibiotics | |
Intubation * | ||
Seizures | ||
Manual placenta detachment | Non-delivered placenta | |
Placental tissue after cesarean section | Curettage necessary | |
Third degree laceration | ||
Fourth degree laceration | ||
Other laceration | Vaginal, perineal, labia | |
Thyroid crisis | ||
Death | ||
Precipitate delivery | ||
Unrecognized maternal disease | ||
Unexpected re-admission | ||
Uterine rupture | ||
Prolonged second stage | >120 min | |
Transmission to intensive care unit* | ||
Placental abruption | ||
Wound healing disorder | ||
Fetal | Near-SIDS | Near Sudden Infant Death Syndrome |
APGAR | 1 min APGAR < 7 | |
Acidosis | Cord pH < 7.1 or base excess < −12 | |
Bradycardia | FHF < 60 | |
Birth trauma | Fracture | |
Seizures | ||
Meconium aspiration | ||
Umbilical cord prolapses | ||
Death | ||
Shoulder dystocia | ||
Unplanned admission to intensive care unit * | ||
Interventional | Transfusion | |
Failed anesthesia | ||
Failed instrumental vaginal delivery | Cesarean section necessary | |
Failed induction of labor | Cesarean section necessary | |
Communication problem | ||
Emergency hysterectomy | ||
Emergency cesarean section | ||
Unplanned cesarean section | ||
Use of more than 1 instrument in vaginal delivery | ||
Delayed intervention in case of pathological CTG | Decision-delivery time > 30 min | |
Delayed intervention in case of postpartum hemorrhage (PPH) | ||
Cesarean section on request | No medical indication | |
Organizational | Incomplete documentation | |
Medication errors | ||
Communication problems |
Category pAE | Cases | Proportion from n = 88 Cases |
---|---|---|
Peripartum therapy delay | 39 | 44.32% |
Diagnostic error | 32 | 36.36% |
Inadequate maternal birth position | 30 | 34.09% |
Organizational errors | 29 | 32.95% |
Inadequate fetal monitoring | 16 | 18.18% |
Medication error | 2 | 2.27% |
Risk Factors | Cases | Proportion | Category |
---|---|---|---|
Primiparous | 49 | 55.68% | Maternal |
Multiparous (defined as two births or more) | 39 | 44.32% | Maternal |
On-call duty | 39 | 44.32% | Organizational |
Induction of labor (IOL) | 38 | 43.18% | Peripartal |
Missed date of birth | 31 | 35.23% | Fetal |
Obesity | 21 | 23.86% | Maternal |
Premature rupture of membranes (PROM) | 19 | 21.59% | Fetal |
Back position at birth | 18 | 20.45% | Peripartal |
Language barrier | 18 | 20.45% | Maternal |
Maternal age > 35 | 15 | 17.05% | Maternal |
Condition after cesarean section (CS) | 12 | 13.64% | Maternal |
Preeclampsia | 9 | 10.23% | Maternal |
Missed diagnosis of preexisting diseases | 8 | 9.09% | Maternal |
Gestational diabetes (GDM) | 7 | 7.95% | Maternal |
Large for gestational age (LGA) | 6 | 6.82% | Fetal |
Insulin-dependent gestational diabetes (IDGDM) | 5 | 5.68% | Maternal |
Missed correct diagnosis of varieties in fetal positions | 4 | 4.55% | Fetal |
Missed diagnosis of allergy | 3 | 3.41% | Maternal |
Diabetes mellitus (DM) type I | 1 | 1.14% | Maternal |
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Hüner, B.; Derksen, C.; Schmiedhofer, M.; Lippke, S.; Janni, W.; Scholz, C. Preventable Adverse Events in Obstetrics—Systemic Assessment of Their Incidence and Linked Risk Factors. Healthcare 2022, 10, 97. https://doi.org/10.3390/healthcare10010097
Hüner B, Derksen C, Schmiedhofer M, Lippke S, Janni W, Scholz C. Preventable Adverse Events in Obstetrics—Systemic Assessment of Their Incidence and Linked Risk Factors. Healthcare. 2022; 10(1):97. https://doi.org/10.3390/healthcare10010097
Chicago/Turabian StyleHüner, Beate, Christina Derksen, Martina Schmiedhofer, Sonia Lippke, Wolfgang Janni, and Christoph Scholz. 2022. "Preventable Adverse Events in Obstetrics—Systemic Assessment of Their Incidence and Linked Risk Factors" Healthcare 10, no. 1: 97. https://doi.org/10.3390/healthcare10010097