IQ healthcare, Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, 114 IQ healthcare, P,O, Box 9101, 6500, HB Nijmegen, The Netherlands.
BMC Pregnancy Childbirth. 2013 Nov 29;13:219. doi: 10.1186/1471-2393-13-219.
This study aimed to perform a structural analysis of determinants of risk of critical incidents in care for women with a low risk profile at the start of pregnancy with a view on improving patient safety.
We included 71 critical incidents in primary midwifery care and subsequent hospital care in case of referral after 36 weeks of pregnancy that were related to substandard care and for that reason were reported to the Health Care Inspectorate in The Netherlands in 36 months (n = 357). We performed a case-by-case analysis, using a previously validated instrument which covered five broad domains: healthcare organization, communication between healthcare providers, patient risk factors, clinical management, and clinical outcomes.
Determinants that were associated with risk concerned healthcare organization (n = 20 incidents), communication about treatment procedures (n = 39), referral processes (n = 19), risk assessment by telephone triage (n = 10), and clinical management in an out of hours setting (n = 19). The 71 critical incidents included three cases of maternal death, eight cases of severe maternal morbidity, 42 perinatal deaths and 12 critical incidents with severe morbidity for the child. Suboptimal prenatal risk assessment, a delay in availability of health care providers in urgent situations, miscommunication about treatment between care providers, and miscommunication with patients in situations with a language barrier were associated with safety risks.
Systematic analysis of critical incidents improves insight in determinants of safety risk. The wide variety of determinants of risk of critical incidents implies that there is no single intervention to improve patient safety in the care for pregnant women with initially a low risk profile.
本研究旨在对妊娠初期低风险孕妇的护理中关键事件风险因素进行结构分析，以期提高患者安全性。
我们纳入了 71 例初级助产护理中的关键事件和后续医院护理中的关键事件，这些事件涉及到标准护理不足，因此在 36 个月内向荷兰医疗保健监察局报告（n=357）。我们使用了一种先前经过验证的工具进行逐案分析，该工具涵盖了五个广泛的领域：医疗保健组织、医疗保健提供者之间的沟通、患者风险因素、临床管理和临床结果。
与风险相关的决定因素包括医疗保健组织（n=20 例事件）、治疗程序沟通（n=39 例）、转诊流程（n=19 例）、电话分诊风险评估（n=10 例）和非工作时间的临床管理（n=19 例）。这 71 例关键事件包括 3 例产妇死亡、8 例严重产妇发病率、42 例围产期死亡和 12 例儿童严重发病率的关键事件。产前风险评估不理想、紧急情况下医疗保健提供者可用性延迟、治疗提供者之间的沟通失误以及语言障碍情况下与患者的沟通失误与安全风险相关。
对关键事件的系统分析提高了对安全风险因素的认识。关键事件风险的决定因素多种多样，这意味着没有单一的干预措施可以改善对初始低风险孕妇的护理。
