Les erreurs en médecine : pourquoi et comment en parler ?

Identifying barriers from home to the appropriate hospital through near-miss audits in developing countries

Near-miss cases often arrive in critical condition in referral hospitals in developing countries. Understanding the reasons why women arrive at these hospitals in a moribund state is crucial to the reduction of the incidence and case fatality of severe obstetric complications. This paper discusses how near-miss audits can empower the hospital teams to document and help reduce barriers to obstetric care in the most useful way and makes practical suggestions on interviews, analytical framework, ethical issues and staff motivation. Review of the evidence shows that case reviews and confidential enquiries appear particularly suitable to the understanding of delays. Criterion-based audits can also achieve this by establishing criteria for referral. However, hospital staff have limited intervention tools at their disposal to address barriers to emergency care at the community level. It is therefore important to involve the district management team and representatives of the community in auditing the health care seeking and treatment of women with near-miss complications.

The difficulty of questioning clinical practice: experience of facility-based case reviews in Ouagadougou, Burkina Faso

OBJECTIVE

To describe the implementation of facility-based case reviews (medical audits) in a maternity unit and their effect on the staff involved.

DESIGN

Cross-sectional descriptive study.

SETTING

A 26-bed obstetric unit in a district hospital in Ouagadougou, Burkina Faso.

SAMPLE

Sixteen audit sessions conducted between February 2004 and June 2005. Thirty-five staff members were interviewed.

METHODS

An analysis of all the tools used in the management of the audit was performed: attendance lists, case summary cards and register of recommendations. The perceptions of the staff about the audits were collected through a questionnaire administrated by an external investigator from 10 June 2005 to 16 June 2005.

MAIN OUTCOME MEASURES

Session participation, types of problems identified, recommendations proposed and implemented and staff reaction to the audits.

RESULTS

Only 7 midwives from a total of 15 regularly attended the sessions. Eighty-two percent of the recommendations made during the audits have been implemented, but sometimes after a delay of several months. Interviewed personnel had a good understanding of the audit goals and viewed audit as a factor in changing their practice. However, midwives highlighted problems of bad interpersonal communication and lack of anonymity during the audit sessions, and pointed out the difficulty of practising self-criticism.

CONCLUSIONS

A lack of staff commitment and the resistance of maternity personnel to being evaluated by their peers or service users are reducing acceptance of routine audits. The World Health Organization must take all these factors into account when promoting the institutionalisation of medical audits in obstetrics.