Impacts of participating in confidential enquiry panels: a qualitative study

Adverse events reporting by obstetric units in Norway as part of their quality assurance and patient safety work: an analysis of practice

BACKGROUND

The Norwegian Board of Health Supervision aims to contribute to the improvement of quality and patient safety in the healthcare services. Planned audits were performed to investigate how 12 selected Norwegian obstetric units reported and analyzed adverse events as the part of their quality assurance and patient safety work.

METHODS

Serious adverse events coded as birth asphyxia, shoulder dystocia and severe postpartum hemorrhage that occurred during 2014 (the most recent year for which the quality assured data were available) were obtained from the Medical Birth Registry of Norway. The obstetric units were asked to submit medical records, internal adverse events reports, and their internal guidelines outlining which events should be reported to the quality assurance system. We identified the adverse events at each obstetric unit that were reported internally and/or to the central authorities. Two obstetricians carried out an evaluation of each event reported.

RESULTS

Five hundred fifty-three serious adverse events were registered among 17,323 births that took place at the selected units. Twenty-one events were excluded because of incorrect coding or missing information. Eight events were registered in more than one category, and these were distributed to the category directly related to injury or adverse outcome. Nine of twelve (75 %) obstetric units had written guidelines describing which events should be reported. The obstetric units reported 49 of 524 (9.3 %) serious adverse events in their internal quality assurance system and 39 (7.4 %) to central authorities. Of the very serious adverse events, 29 of 149 (19.4 %) were reported. Twenty-three of 49 (47 %) reports did not contain relevant assessments or proposals for improving quality and patient safety.

CONCLUSIONS

This study showed that adverse event reporting and analyses by Norwegian obstetric units, as a part of quality assurance and patient safety work, are suboptimal. The reporting culture and compliance with guidelines need to be improved substantially for better safety in patient care, risk mitigation and clinical quality assurance.

Seeking solutions: scaling-up audit as a quality improvement tool for infection control in Gujarat, India

QUALITY PROBLEM OR ISSUE

Surgical-site infections (SSIs) give rise to significant demands on the health systems as well as economic and social sequelae for patients. This article describes an audit for infection control developed in a surgical unit of a tertiary care setting in Gujarat state, India that was scaled-up to all state-owned hospitals in the district.

INITIAL ASSESSMENT

A retrospective baseline assessment of surgical infection rates in a general surgical unit revealed an infection rate of 30%.

CHOICE OF SOLUTION

An audit was implemented based on guidelines for SSI prevention published by the Centres of Disease Control.

IMPLEMENTATION

Surveillance and hospital epidemiology were established and practice reforms implemented. Monthly and annual meetings to review implementation were held.

EVALUATION

After 12 months, an 88% decrease in the infection rate in the surgical unit was demonstrated. Thereafter, the process was replicated across the surgical department and for all cases undergoing surgery. After 12 months, a 67% reduction in the infection rate was detected. The process has since been applied across the state.

LESSONS LEARNED

A locally owned and team-led process embedded within routine working conditions can challenge widely held perceptions, inform low-cost and no-cost remedial actions, and improve cultures of practice, quality of care and health outcomes. As urban populations grow, methods that are capable of continuously identifying, and responding to, problems and sustaining quality of care in facilities are necessary. SSIs may be largely preventable. With careful implementation, audit has the potential to be a major contributor to their reduction.

National maternal mortality ratio for Jordan, 2007-2008

OBJECTIVE

To estimate the number of maternal deaths per 100000 live births during 2007-2008 among Jordanian women; to identify the causes of maternal mortality; and to compare the results with those of the last report for 1995-1996.

METHODS

Reproductive-age mortality study of maternal deaths among women aged 15-49 years in Jordan in 2007-2008.

RESULTS

Among 1406 identified deaths of reproductive-aged women, 76 maternal deaths were identified out of 397588 live births, for a maternal mortality ratio of 19.1 deaths per 100000 live births. Forty-three (56.6%) deaths were attributable to hemorrhage, thrombosis and thromboembolism, and sepsis. Avoidable factors were present in 53.9% of women, 52.6% had substandard care, and 31.5% had 3 or fewer antenatal visits. Of those with available information on family planning, only 29.4% had ever used any form of contraception.

CONCLUSIONS

Maternal deaths in Jordan are declining. The maternal mortality ratio of 19.1 deaths per 100000 live births reported for 2007-2008 showed a remarkable reduction of 53.9% achieved in the 12 years since the 1995-1996 report (a 4.5% annual reduction), which is approaching the 75% reduction recommended by Millennium Development Goal 5.

A population-based surveillance study on severe acute maternal morbidity (near-miss) and adverse perinatal outcomes in Campinas, Brazil: the Vigimoma Project

BACKGROUND

Auditing of sentinel health events based on best-practice protocols has been recommended. This study describes a population-based investigation on adverse perinatal events including severe acute maternal morbidity (near-miss), maternal and perinatal mortality, as a health intervention to help improve the surveillance system.

METHODS

From October to December 2005, all cases of maternal death (MD), near-miss (NM), fetal deaths (FD), and early neonatal deaths (END), occurring in Campinas, Brazil, were audited by maternal mortality committees.

RESULTS

A total of 4,491 liveborn infants (LB) and 159 adverse perinatal events (35.4/1000 LB) were revised, consisting of 4 MD (89/100.000 LB) and 95 NM (21.1/1000 LB), 23.7 NM for each MD. In addition, 32 FD (7.1/1000 LB) and 28 END (6.2/1000 LB) occurred. The maternal death/near miss rate was 23.7:1. Some delay in care was recognized for 34%, and hypertensive complications comprised 57.8% of the NM events, followed by postpartum hemorrhage.

CONCLUSION

Auditing near miss cases expanded the understanding of the spectrum from maternal morbidity to mortality and the importance of promoting adhesion to clinical protocols among maternal mortality committee members. Hypertensive disorders and postpartum hemorrhage were identified as priority topics for health providers training, and organization of care.

Introducing maternal morbidity audit in the Netherlands

OBJECTIVE

To describe the panel audit process and to identify substandard care in selected women from a nationwide prospective cohort study into severe acute maternal morbidity (SAMM) in the Netherlands.

DESIGN

Prospective audit of selected women with SAMM.

SETTING

Eight audit meetings held throughout the Netherlands.

POPULATION

All pregnant women in the Netherlands.

METHODS

Before each meeting, SAMM details of selected women were sent to all panel members for individual assessment by completing an audit form. During a subsequent plenary meeting, findings were discussed and substandard care factors as judged by the majority of assessors were scored.

MAIN OUTCOME MEASURES

Incidence of substandard care and recommendations for improving the quality of care.

RESULTS

Substandard care was identified in 53 of 67 women (79%). Specific recommendations were formulated concerning the procedure of audit and concerning local as well as national management guidelines.

CONCLUSION

Our findings reflect SAMM in the Netherlands and substandard care is present in four out of five women. Ongoing audit of women with SAMM is promoted both at local and national level.

Assessing quality of care provided by Indonesian village midwives with a confidential enquiry

OBJECTIVE

to conduct a confidential enquiry to assess the quality of care provided by Indonesian village midwives and to identify opportunities for improvement.

METHODS

local health-care practitioners assessed village-based care in obstetric emergencies in 13 cases of maternal death and near-miss from rural villages in West Java. The study focused on clinical quality of care, but also investigated the influence of the health system and social factors. The reviews were based on transcripts of interviews with health-care providers, family and community members involved in the cases. Both favourable and adverse factors were identified in order to recognise positive contributions, where they occurred. At the end of a series of case reviews, recommendations for practice were generated and disseminated.

FINDINGS

in the cases reviewed, midwives facilitated referral effectively, reducing delays in reaching health facilities. Midwives' emergency diagnostic skills were accurate but they were less capable in the clinical management of complications. Coverage was poor; in some locations, midwives were responsible for up to five villages. Village midwives were also perceived as unacceptable to women and their families. Families and communities did not prepare for emergencies with finances or transport, partly due to a poorly understood health insurance system. The enquiry had learning effects for those involved.

KEY CONCLUSIONS

village midwives should: receive appropriate support for the management of obstetric emergencies; engage with communities to promote birth preparedness; and work in partnership with formal and informal providers in the community. The enquiry was a diagnostic tool to identify opportunities for improving care. Practitioners had a unique insight into factors that contribute to quality care and how feasible interventions might be made.