Chikwiri Christopher, Chauke Lawrence
Department of Obstetrics and Gynaecology, University of the Witwatersrand and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa.
Pan Afr Med J. 2024 Aug 28;48:189. doi: 10.11604/pamj.2024.48.189.38552. eCollection 2024.
critical incidents are among the ten leading causes of death and disability worldwide. Improving patient safety is a global priority and one way of achieving this goal is to report and analyse critical incidents. We aimed to establish the incidence, describe the profile, patient outcomes and avoidable factors associated with gynaecological critical incidents in an academic hospital in Johannesburg, South Africa.
this is a retrospective descriptive analysis of critical incidents in patients admitted to gynaecology wards at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) from 1 January 2019 to 31 December 2019. All medical records of patients identified to have experienced critical incidents were reviewed and demographic information, timing of admission, critical incidence markers and avoidable factors were extracted and analysed.
there was a total of 176 critical incident events and 2082 gynaecology admissions during the 1-year study period. Only 158 critical incident files were available and complete to enable analysis. This gave a critical incidence rate of 7.6% (158/2082). The mean age (SD) of the patients was 41.1 (14.8) years and the median (IQR) duration of admission was 6 (3-10) days. The main causes of critical incidents were omission of procedures (n=45, 17.5%), deaths (n=34, 13.2%), massive transfusion (n=30, 11.7%), repeat laparotomies (n=29, 11.3%) and fistula/organ damage (n=19, 7.4%). There were 111 (70.3%) avoidable factors in the 158 critical incident cases. Most of the avoidable factors were medical care related, 53 (47.8%), followed by administrative factors, 33 (29.7%) with patient-related factors in the least at, 25 (22.5%). Critical incident forms were only filled out in 39 out of the 176 (22.2%) patients identified to have suffered a critical incident.
the critical incidents rate in this institution is within the range reported in the literature however underreporting is a major concern. The leading causes of critical incidents were omission of procedure, followed by deaths. Approximately two-fifths of the critical incidents were associated with some form of harm, ranging from mild disability to deaths. Most of the avoidable factors were health system-related (medical care and administrative). The department should focus on improving critical incident reporting systems and the quality of care to reduce the number of critical incidents.
危急事件是全球十大主要死因和致残原因之一。提高患者安全是全球的优先事项，实现这一目标的一种方法是报告和分析危急事件。我们旨在确定南非约翰内斯堡一家学术医院中妇科危急事件的发生率，描述其概况、患者结局以及相关的可避免因素。
这是一项对2019年1月1日至2019年12月31日在夏洛特·马克西克约翰内斯堡学术医院（CMJAH）妇科病房住院患者发生的危急事件进行的回顾性描述性分析。对所有被确定经历过危急事件的患者的病历进行审查，提取并分析人口统计学信息、入院时间、危急事件标志物和可避免因素。
在为期1年的研究期间，共发生176起危急事件，妇科入院患者2082例。仅有158份危急事件档案可供完整分析。这得出危急事件发生率为7.6%（158/2082）。患者的平均年龄（标准差）为41.1（14.8）岁，入院中位时间（四分位间距）为6（3 - 10）天。危急事件的主要原因是手术遗漏（n = 45，17.5%）、死亡（n = 34，13.2%）、大量输血（n = 30，11.7%）、再次剖腹手术（n = 29，11.3%）以及瘘管/器官损伤（n = 19，7.4%）。在158例危急事件病例中有111例（70.3%）存在可避免因素。大多数可避免因素与医疗护理相关，占53例（47.8%），其次是行政因素，占33例（29.7%），与患者相关的因素最少，占25例（22.5%）。在被确定发生危急事件的176例患者中，只有39例（22.2%）填写了危急事件表格。
该机构的危急事件发生率在文献报道范围内，但上报不足是一个主要问题。危急事件的主要原因是手术遗漏，其次是死亡。大约五分之二的危急事件与某种形式的伤害相关，从轻度残疾到死亡不等。大多数可避免因素与卫生系统相关（医疗护理和行政）。该科室应专注于改进危急事件报告系统和护理质量，以减少危急事件的数量。
