The Ottawa hospital quality incident notification system for capturing adverse events in obstetrics.

OBJECTIVE: To describe the design and implementation of a Quality Incident Notification (QIN) system in an obstetrical unit and provide an analysis of the frequency and nature of events captured by the system. METHODS: We implemented a system to capture quality events, consisting of an on-line form that was easily accessible to all levels of staff. A list of quality indicators was developed to indicate potential safety concerns, near misses, or poor outcomes that required closer scrutiny. We retrospectively analyzed the cases reported in the first year following introduction of the QIN for the presence, severity, and avoidability of harm. RESULTS: During the 12-month study period there were 6752 deliveries, and 578 QINs were generated, a rate of one QIN for every 11.7 deliveries (8.5%). The most frequent indicators reported were "neonatal near miss" (15.4%), "records/results" (14.5%), and "staff communication" (10.0%). Out of the 497 QINs with complete data, 67 (13.4%) showed minor harm to the mother, the baby, or both, and 37 (7.4%) QINs showed major harm. Only 28 of the 110 cases of actual harm were considered to be caused by the medical care (0.4% of all deliveries), and 14 patients were judged to have experienced avoidable actual harm due to medical care (0.2% of all deliveries). CONCLUSION: The QIN system captured a relatively low rate of adverse events, with about half of these being avoidable. Used consistently, this type of system can be an effective tool for risk management and improvement of practices.

Adverse events detected by clinical surveillance on an obstetric service.

OBJECTIVE: Adverse events are adverse patient outcomes resulting from medical care. We performed this study to estimate the rate of adverse events and potential adverse events-errors that have a high likelihood of causing patient harm-occurring during obstetric care. METHODS: This was a prospective cohort study of an obstetric unit in a teaching hospital. We included patients admitted consecutively to the hospital. A trained observer monitored patients for 72 triggers, which were predefined occurrences deemed likely to indicate an actual or potential adverse event. When a trigger occurred, the observer captured information describing it. A five-person multidisciplinary team, including the observer, three physicians, and a hospital risk manager, judged whether the trigger represented an adverse event or potential adverse event. Adverse events were further characterized as preventable. RESULTS: The cohort included 425 patients; 47% were in active labor. We identified 110 triggers. Nine were considered adverse events (risk 2%, 95% confidence interval [CI] 1-4%, rate 0.8 events per 100 patient days), and six were preventable (risk 1%, 95% CI 0-3%, rate 0.5 events per 100 patient days). The remaining triggers included 14 potential adverse events (risk 3%, 95% CI 2-5%, rate 1.3 events per 100 patient days). No adverse event resulted in permanent disability or death. Adverse events and potential adverse events were most commonly "system" problems, such as unavailable staff or operating rooms, or poor fetal outcomes, such as trauma to the newborn. CONCLUSION: Serious adverse events occur infrequently on an obstetric service. However, important quality problems are common and should be targeted for improvement. LEVEL OF EVIDENCE: II-2.