Retrospective Observational Study of the Frequency and Interrelationships Among Neonatal Near Miss Criteria.

OBJECTIVE: To evaluate the frequency and interrelationships among neonatal near miss (NNM) criteria and the anticipated workload for audits in high-income countries. DESIGN: Observational retrospective descriptive study. SETTING: Tertiary maternal and neonatal units at Mater Mothers' Hospital, Brisbane, Queensland, Australia. PARTICIPANTS: Cases of stillbirths (n = 483), neonatal deaths (n = 203), and live births (n = 66,353) from January 2016 to July 2022 (N = 67,039). METHODS: We identified eight prespecified NNM criteria nominated by perinatal experts. Primary outcomes were NNM frequency, their interrelationships, and related workload. We used descriptive statistics and analysis of variance and considered p < .05 significant. RESULTS: We found 2,243 unique NNM cases (33.7/1,000 live births). The NNM ratio per 1,000 live births according to each of the eight criteria were: unplanned resuscitation at birth (25.09/1,000 live births), birth asphyxia needing surveillance for hypoxic ischemic encephalopathy (8.46/1,000 live births), metabolic acidosis at birth (8.04/1,000 live births), advanced resuscitation at birth (3.68/1,000 live births), seizures and/or stroke (0.96/1,000 live births), severe intraventricular hemorrhage and/or cerebellar hemorrhage (0.95/1,000 live births), moderate to severe hypoxic ischemic encephalopathy (0.9/1,000 live births), and severe birth trauma (0.44/1,000 live births). Almost one third of NNM cases met more than one criterion. Anticipated workload for monthly NNM audits varied from 0.04 to 2.8 cases per 1,000 live births. CONCLUSION: Different sets of NNM criteria considerably alter the frequency of NNMs and the anticipated workload for NNM audits. Their interrelationships are likely attributable to the fact that some of the criteria are risk factors for or are part of the causal pathway for other NNM criteria. These findings can assist with the determination of a pragmatic NNM definition considering the feasibility of NNM audits in high-income countries.

Relationship Between Companies' Responses to Near-Miss Reports and Turnover Intentions of Workers: A Nationwide Cross-Sectional Study.

Background: Effective near-miss management is important in preventing workplace accidents. A company's inadequate response to near-miss reports can lead workers to feel insecure and dissatisfied with the company. We investigated the relationship between companies' responses to near-miss reports and turnover intentions of workers. Methods: We conducted a cross-sectional study using online self-administered questionnaire survey to workers aged ≥20 years in Japan in March 2022. The analysis included 5,071 participants who had near-miss experiences and reported them to their companies. The independent variable was companies' responses to near-miss reports, classified into three categories: adequate response group, inadequate response group, and no response group. The dependent variable was turnover intentions. We calculated the odds ratio and 95% confidential interval (CI) using multilevel logistic regression analyses nested for industries and adjusted for covariates. Results: Of the 5,071 participants, 3,058 (60.3%) were adequate response group, 1,484 (29.3%) were inadequate response group, and 529 (10.4%) were no response group. In multivariable adjusted model, compared with adequate response group, the odds ratio of inadequate response group and no response group were 1.80 (95% CI: 1.56-2.08) and 2.63 (95% CI: 2.15-3.22), respectively. Conclusion: Our results suggested that there was a relationship between companies' responses to the near-miss reports and turnover intentions of workers. It is important not only to collect near-misses but also to respond appropriately to the reports and provide feedback to workers.

Enabling Effective Implementation of Occupational Safety and Health Interventions.

Background: The design, implementation, and evaluation are three important stages of occupational safety and health (OSH) interventions. Historically, there has been a tendency to prioritize implementation, often neglecting detailed design and rigorous outcome evaluation. Currently, much has changed, and contemporary approaches recognize the interdependence of these stages, considering them integral to the success of any intervention. This work presents a comprehensive procedure for implementing interventions, not only to ensure short-term effectiveness but also their long-term sustainability through continuous monitoring. The focus is on a national OSH project introducing a near-miss management system (NMS) in Italy. Methods: Initial meetings were convened among project partners, complemented by interviews with diverse stakeholders, to plan implementation steps and test the NMS. Tailored questionnaires were designed for diverse stakeholder groups - initial promoters, company managers and employers, and employees - facilitating targeted implementation, and three case studies were started in Italian regions to assess the structured implementation, involving intervention promoters and collaborating companies. Results: The primary outcome is the development of practical tools, specifically three questionnaires, which are considered valuable for establishing an effective human-centered implementation strategy, meticulously designed to facilitate ongoing monitoring of processes and continual enhancement of instruments intended for NMS integration within companies. Conclusions: This work lays the foundation for successful NMS implementation in Italy and, although the outlined procedure had specific objectives, it also provides valuable insights applicable in enhancing the effectiveness and sustainability of interventions across diverse contexts. It underscores the importance of comprehensive planning, stakeholder engagement, and continuous evaluation in achieving lasting OSH interventions.

Barriers to Incident Reporting by Physicians: A Survey of Surgical Residents and Attending Physicians.

Objectives Incident reporting is vital to a culture of safety; however, physicians report at an alarmingly low rate. This study aimed to identify barriers to incident reporting among surgeons at a quaternary care center. Methods A survey was created utilizing components of the Agency for Healthcare Research and Quality (AHRQ) validated survey on patient safety culture. This tool was distributed to residents and attending physicians in general surgery and urology at a single academic medical center. Responses were de-identified and recorded for data analysis using REDCap (Research Electronic Data Capture) database tool (Vanderbilt University, Nashville, Tennessee, United States). Results We received 39 survey responses from 116 residents and attending physicians (34% response rate), including nine urologists and 30 general surgeons (24 attendings, 15 residents). Residents and attendings feel the person is being written up and not the issue (67%) and that there is a lack of feedback after changes are implemented (64%), though most believe adequate action is taken to address patient safety concerns (72%). Most do not report near-misses (64%), only significant adverse events (59%). Residents are likely to stay silent when patient safety events involve those in authority (60%). Faculty feel those in authority are open to patient safety concerns (67%), though residents feel neutral (47%) or disagree (33%). Conclusion Underreporting of incidents among physicians remains multifaceted and complex, from fear of retaliation to lack of feedback. Residents tend to feel less comfortable addressing authority figures when concerned about patient safety. While misunderstanding still exists about the applications and utility of incident reporting, a focus on quality over quantity could afford more meaningful progress toward high reliability in healthcare.

Predictors of neonatal near-misses in Worabe Comprehensive Specialized Hospital, Southern Ethiopia.

Background: Neonatal deaths are still a major leading cause of social and economic crises. Identifying neonatal near-miss events and identifying their predictors is crucial to developing comprehensive and pertinent strategies to alleviate neonatal morbidity and death. However, neither neonatal near-miss events nor their predictors were analyzed in the study area. Therefore, this study is aimed at assessing the predictors of neonatal near-misses among neonates born at Worabe Comprehensive Specialized Hospital, Southern Ethiopia, in 2021. Methods: A hospital-based unmatched case-control study was conducted from 10 November 2021 to 30 November 2021. A pre-tested, structured, and standard abstraction checklist was used to collect the data. After checking the data for completeness and consistency, it was coded and entered into Epi-Data 3.1 and then exported to Stata version 14 for analysis. All independent variables with a p-value ≤0.25 in bivariable binary logistic regression were entered into a multivariable analysis to control the confounding. Variables with p-values <0.05 were considered statistically significant. Results: In this study, 134 neonatal near-miss cases and 268 controls were involved. The identified predictors of neonatal near-misses were rural residence [adjusted odds ratio (AOR): 2.01; 95% confidence interval (CI): 1.31-5.84], no antenatal care (ANC) follow-up visits (AOR: 2.98; 95% CI: 1.77-5.56), antepartum hemorrhage (AOR: 2.12; 95% CI: 1.18-4.07), premature rupture of the membrane (AOR: 2.55; 95% CI: 1.54-5.67), and non-vertex fetal presentation (AOR: 3.05; 95% CI: 1.93-5.42). Conclusion: The current study identified rural residents, no ANC visits, antepartum hemorrhage, premature rupture of membrane, and non-vertex fetal presentation as being significantly associated with neonatal near-miss cases. As a result, local health planners and healthcare practitioners must collaborate in enhancing maternal healthcare services, focusing specifically on the early identification of issues and appropriate treatment.

A prospective cohort study of perceived organizational support and occupational accidents and near-miss events among Japanese workers.

INTRODUCTION: Preventing occupational accidents is a major global challenge, and employee safety practices play a crucial role in accident prevention. Although perceived organizational support (POS) is related to safety practices, there is currently insufficient evidence supporting a relationship between POS and occupational accidents. We investigated the relationships between POS and both occupational accidents and near-miss events that can lead to accidents in the following year among workers in various industries in Japan. METHOD: This prospective cohort study was conducted from March 2022 to March 2023 using a questionnaire survey. In total, 9916 participants who completed the follow-up survey and met our inclusion criteria were analyzed. The follow-up survey asked participants about both occupational accidents and near-miss events experienced in the year following the baseline assessment. POS was evaluated at baseline using the eight-item version of the Survey of Perceived Organizational Support. Odds ratios (ORs) for the relationships between POS and occupational accidents and near-miss events were estimated using multilevel logistic regression analyses nested by industries. RESULTS: The ORs for self-reported occupational accidents were significantly higher for the moderate (OR = 1.41, 95% confidence interval [CI]: 1.10-1.82), low (OR = 1.49, 95%CI: 1.18-1.89), and very low (OR = 2.03, 95%CI: 1.61-2.56) POS groups compared with the very high group. The ORs for self-reported near-miss events were also significantly higher for the moderate (OR = 1.21, 95%CI: 1.03-1.43), low (OR = 1.20, 95%CI: 1.03-1.40), and very low (OR = 1.56, 95%CI: 1.34-1.82) groups than the very high group. CONCLUSIONS: Our findings suggest lower POS is related to a higher occurrence of occupational accidents and near-miss events in the following year. Organizations should consider enhancing employees' POS to reduce occupational accidents and near-miss events. PRACTICAL APPLICATIONS: To enhance employees' POS, organizations should address identified antecedents of POS (e.g., fairness, supervisor support, rewards, favorable job conditions, and human resource practices).

Risk factors for maternal near-miss in an undeveloped province in south-central China, 2012-2022.

OBJECTIVE: To explore the risk factors for maternal near-miss (MNM) using the WHO near-miss approach. METHODS: Data were obtained from the Maternal Near-Miss Surveillance System in Hunan Province, China, 2012-2022. Multivariate logistic regression analysis (method: Forward, Wald, α = 0.05) and adjusted odds ratios (aORs) were used to identify risk factors for MNM. RESULTS: Our study included 780,359 women with 731,185 live births, a total of 2461 (0.32%) MNMs, 777,846 (99.68%) non-MNMs, and 52 (0.006%) maternal deaths were identified. The MNM ratio was 3.37‰ (95%CI: 3.23-3.50). Coagulation/hematological dysfunction was the most common cause of MNM (75.66%). Results of multivariate logistic regression analysis showed risk factors for MNM: maternal age > = 30 years old (aOR > 1, P < 0.05), unmarried women (aOR = 2.21, 95%CI: 1.71-2.85), number of pregnancies > = 2 (aOR > 1, P < 0.05), nulliparity (aOR = 1.51, 95%CI: 1.32-1.72) or parity > = 3 (aOR = 1.95, 95%CI: 1.50-2.55), prenatal examinations < 5 times (aOR = 1.13, 95%CI: 1.01-1.27), and number of cesarean sections was 1 (aOR = 1.83, 95%CI: 1.64-2.04) or > = 2 (aOR = 2.48, 95%CI: 1.99-3.09). CONCLUSION: The MNM ratio was relatively low in Hunan Province. Advanced maternal age, unmarried status, a high number of pregnancies, nulliparity or high parity, a low number of prenatal examinations, and cesarean sections were risk factors for MNM. Our study is essential for improving the quality of maternal health care and preventing MNM.

Critical airway-related incidents and near misses in anaesthesia: a qualitative study of a critical incident reporting system.

BACKGROUND: Many serious adverse events in anaesthesia are retrospectively rated as preventable. Anonymous reporting of near misses to a critical incident reporting system (CIRS) can identify structural weaknesses and improve quality, but incidents are often underreported. METHODS: This prospective qualitative study aimed to identify conceptions of a CIRS and reasons for underreporting at a single Swiss centre. Anaesthesia cases were screened to identify critical airway-related incidents that qualified to be reported to the CIRS. Anaesthesia providers involved in these incidents were individually interviewed. Factors that prevented or encouraged reporting of critical incidents to the CIRS were evaluated. Interview data were analysed using the Framework method. RESULTS: Of 3668 screened airway management procedures, 101 cases (2.8%) involved a critical incident. Saturation was reached after interviewing 21 anaesthesia providers, who had been involved in 42/101 critical incidents (41.6%). Only one incident (1.0%) had been reported to the CIRS, demonstrating significant underreporting. Interviews revealed highly variable views on the aims of the CIRS with an overall high threshold for reporting a critical incident. Factors hindering reporting of cases included concerns regarding identifiability of the reported incident and involved healthcare providers. CONCLUSIONS: Methods to foster anonymity of reporting, such as by national rather than departmental critical incident reporting system databases, and a change in culture is required to enhance reporting of critical incidents. Institutions managing a critical incident reporting system need to ensure timely feedback to the team regarding lessons learned, consequences, and changes to standards of care owing to reported critical incidents. Consistent reporting and assessment of critical incidents is required to allow the full potential of a critical incident reporting system.

Concept analysis of Neonatal Near Miss.

OBJECTIVE: To analyze the concept of Neonatal Near Miss (NNM) using Walker and Avant's method. METHOD: This study employs conceptual analysis following Walker and Avant's model, involving concept selection, objective definition, identification of potential uses, determination of attributes, model case creation, additional case consideration, antecedent identification, consequent analysis, and empirical reference examination. To elucidate the concept, a scoping review was conducted across journals indexed in scientific databases such as Web of Science, EMBASE, SCOPUS, and MEDLINE/PubMed. RESULTS: The analysis encompassed 43 articles, revealing diverse definitions of neonatal near miss across different contexts. A comprehensive definition emerged from identified antecedents: risk of death, susceptibility to adverse outcomes, and potential adverse events. These antecedents were categorized into maternal conditions, neonatal conditions, and healthcare assistance. CONCLUSION: The analysis and definition of the NNM concept was successful, and its antecedents, attributes, and consequences were delineated. IMPLICATIONS: Identifying the risk factors associated with NNM cases may contribute to reducing infant morbidity and mortality and improving the quality of care, facilitating future research and improving the use of the NNM concept.

Predictors and a scoring model for maternal near-miss and maternal death in Southern Thailand: a case-control study.

PURPOSE: To identify predictors and develop a scoring model to predict maternal near-miss (MNM) and maternal mortality. METHODS: A case-control study of 1,420 women delivered between 2014 and 2020 was conducted. Cases were women with MNM or maternal death, controls were women who had uneventful deliveries directly after women in the cases group. Antenatal characteristics and complications were reviewed. Multivariate logistic regression and Akaike information criterion were used to identify predictors and develop a risk score for MNM and maternal mortality. RESULTS: Predictors for MNM and maternal mortality (aOR and score for predictive model) were advanced age (aOR 1.73, 95% CI 1.25-2.39, 1), obesity (aOR 2.03, 95% CI 1.22-3.39, 1), parity ≥ 3 (aOR 1.75, 95% CI 1.27-2.41, 1), history of uterine curettage (aOR 5.13, 95% CI 2.47-10.66, 3), history of postpartum hemorrhage (PPH) (aOR 13.55, 95% CI 1.40-130.99, 5), anemia (aOR 5.53, 95% CI 3.65-8.38, 3), pregestational diabetes (aOR 5.29, 95% CI 1.27-21.99, 3), heart disease (aOR 13.40, 95%CI 4.42-40.61, 5), multiple pregnancy (aOR 5.57, 95% CI 2.00-15.50, 3), placenta previa and/or placenta-accreta spectrum (aOR 48.19, 95% CI 22.75-102.09, 8), gestational hypertension/preeclampsia without severe features (aOR 5.95, 95% CI 2.64-13.45, 4), and with severe features (aOR 16.64, 95% CI 9.17-30.19, 6), preterm delivery <37 weeks (aOR 1.65, 95%CI 1.06-2.58, 1) and < 34 weeks (aOR 2.71, 95% CI 1.59-4.62, 2). A cut-off score of ≥4 gave the highest chance of correctly classified women into high risk group with 74.4% sensitivity and 90.4% specificity. CONCLUSIONS: We identified predictors and proposed a scoring model to predict MNM and maternal mortality with acceptable predictive performance.

The Unmet Needs of Women with Maternal Near Miss Experience: A Qualitative Study.

Introduction: A maternal near-miss (MNM) case is defined as "a woman who nearly died but survived from life-threatening pregnancy or childbirth complication". This study was conducted on health care providers and near-miss mothers (NMMs) with the aim of discovering the unmet needs of Iranian NMM. Methods: In this qualitative study 37 participants of key informants, health providers, NMMs and their husbands were selected using purposive sampling. Semi-structured in-depth interviews were conducted for data collection until data saturation was achieved. Data were analyzed using Graneheim and Lundman conventional content analysis. Results: The analysis revealed the core category of "the need for comprehensive support". Eight categories included "psychological", "fertility", "information", "improvement the quality of care", "sociocultural", "financial", "breastfeeding" and "nutritional" needs emerging from 18 sub-categories, were formed from 2112 codes. Conclusion: Many of the real needs of NMM have been ignored. Maternal health policymakers should provide standard guidelines based on the needs discovered in this study to support the NMMs' unmet needs.

Using the WHO individual near miss case review (NMCR) cycle to improve quality of emergency obstetric care and maternal outcome in Keren hospital, Eritrea: an interrupted time series analysis.

BACKGROUND: In 2016, the WHO regional office for Europe prepared a manual for conducting routine facility based individual near miss case review cycle. This study evaluates the effectiveness of the individual near miss case review (NMCR) cycle in improving quality of emergency obstetric care and maternal outcome in Keren hospital. METHODS: An interrupted time series design was used to achieve the objectives of this study. Monthly data on women with potentially life-threatening conditions (PLTCs) admitted between April 2018 and October 2022 (i.e. 33 months pre-implementation and 22 months post-implementation) were collected from medical records. Segmented regression analysis was used to assess the intervention's effect on three process and outcome measures, namely, SMO, delayed care, and substandard care. The intervention was expected a priori to show immediate improvements without time-lag followed by gradual increment in slope. Segmented regression analyses were performed using the "itsa' command in STATA. RESULTS: During the entire study period, 4365 women with potentially life threatening conditions were identified. There was a significant reduction in the post-implementation period in the proportion of mothers with PLTC who experienced SMO (- 8.86; p <  0.001), delayed care (- 8.76; p <  0.001) and substandard care (- 5.58; p <  0.001) compared to pre-implementation period. Results from the segmented regression analysis revealed that the percentage of women with SMO showed a significant 4.75% (95% CI: - 6.95 to - 2.54, p <  0.001) reduction in level followed by 0.28 percentage points monthly (95% CI: - 0.37 to - 0.14, p <  0.001) drop in trend. Similarly, a significant drop of 3.50% (95% CI: - 4.74 to - 2.26, p <  0.001) in the level of substandard care along with a significant decrease of 0.21 percentage points (95% CI: - 0.28 to - 0.14, p < 0.001) in the slope of the regression line was observed. The proportion of women who received delayed care also showed a significant 7% (95% CI: - 9.28 to - 4.68, p < 0.001) reduction in post-implementation level without significant change in slope. CONCLUSIONS: Our findings suggest that the WHO individual NMCR cycle was associated with substantial improvements in quality of emergency obstetric care and maternal outcome. The intervention also bears a great potential for scaling-up following the guidance provided in the WHO NMCR manual.

Medication errors in veterinary anesthesia: a literature review.

OBJECTIVE: To provide an overview of medication errors (MEs) in veterinary medicine, with a focus on the perianesthetic period; to compare MEs in veterinary medicine with human anesthesia practice, and to describe factors contributing to the risk of MEs and strategies for error reduction. DATABASES USED: PubMed and CAB abstracts; search terms: [("patient safety" or "medication error∗") AND veterin∗]. CONCLUSIONS: Human anesthesia is recognized as having a relatively high risk of MEs. In veterinary medicine, MEs were among the most commonly reported medical error. Predisposing factors for MEs in human and veterinary anesthesia include general (e.g. distraction, fatigue, workload, supervision) and specific factors (e.g. requirement for dose calculations when dosing for body mass, using several medications within a short time period and preparing syringes ahead of time). Data on MEs are most commonly collected in self-reporting systems, which very likely underestimate the true incidence, a problem acknowledged in human medicine. Case reports have described a variety of MEs in the perianesthetic period, including prescription, preparation and administration errors. Dogs and cats were the most frequently reported species, with MEs in cats more commonly associated with harmful outcomes compared with dogs. In addition to education and raising awareness, other strategies described for reducing the risk of MEs include behavioral, communication, identification, organizational, engineering and cognitive aids.

Audit as a tool for improving obstetric care in low- and middle-income countries.

Maternal and/or perinatal death review or audits aim to improve the quality of health services and reduce deaths due to causes identified. A death review audit cycle identifies causes of deaths and possible modifiable factors, these can point to potential breaks in the continuity of health care and other health systems faults and challenges. It is an important function of audit cycles to develop, implement, monitor, and review action plans to improve the service. The WHO has produced two handbooks (Making Every Baby Count and Monitoring Emergency Obstetric Care) to guide maternal and perinatal death reviews. Health worker related factors accounts for two thirds of aspects that, if done differently may have prevented the adverse outcome. This emphasises the need for skilled health care workers at every delivery and for deliveries to take place in health facilities.

What's the CATCH? A Participatory Learning Model for Case Review Rounds to Support a Culture of Safety and Quality Improvement in Pediatric Hospital Medicine.

OBJECTIVE: To evaluate the effectiveness of a new model, Case Analysis and Translation to Care in Hospital (CATCH), for the review of pediatric inpatient cases when an adverse event or "close call" had occurred. STUDY DESIGN: The curricular intervention consisted of an introductory podcast/workshop, mentorship of presenters, and monthly CATCH rounds over 16 months. The study was conducted with 22 pediatricians at a single tertiary care center. Intervention assessment occurred using participant surveys at multiple intervals: pre/post the intervention, presenter experience (post), physicians involved and mentors experience (post), and after each CATCH session. Paired t-tests and thematic analysis were used to analyze data. Time required to support the CATCH process was used to assess feasibility. RESULTS: Our overall experience and data revealed a strong preference for the CATCH model, high levels of engagement and satisfaction with CATCH sessions, and positive presenter as well as physicians-involved and mentor experiences. Participants reported that the CATCH model is feasible, engages physicians, promotes a safe learning environment, facilitates awareness of tools for case analysis, and provides opportunities to create "CATCH of the Day" recommendations to support translation of learning to clinical practice. CONCLUSIONS: The CATCH model has significant potential to strengthen clinical case rounds in pediatric hospital medicine. Future research is needed to assess the effectiveness of the model at additional sites and across medical specialities.

FACTORS ASSOCIATED WITH EXTREME MATERNAL MORBIDITY IN A COHORT OF PREGNANT WOMEN IN A CALI EAPB 2019-2020 / FACTORES ASOCIADOS A LA MORBILIDAD MATERNA EXTREMA EN UNA COHORTE DE GESTANTES DE UNA EAPB CALI 2019-2020

Introduction: Extreme maternal morbidity (EMM) is an event of interest in public health that has an important impact when evaluating health services, since timely and quality care in a woman with a severe obstetric complication can prevent a fatal outcome. In an EAPB in the city of Cali during the 2019-2020 period, a need was evidenced to determine the behavior of the factors mostly associated with extreme maternal morbidity, this being a relevant study to support decision-making. Methodology: it is a type of observational analytical retrospective cohort study, we worked with a census of pregnant women registered in the insurer's nominal follow-up matrix, which is fed from various sources such as the single database of affiliates, SIVIGILA, RIPS among others, a characterization of the sociodemographic, clinical and health care factors was carried out by means of absolute and relative frequencies, later they were crossed in contingency tables to determine association by means of the chi square test and a regression model was carried out. binomial log to establish the factors that best explain EMM. Results: most of the pregnant women were between 18 and 35 years old, from the subsidized regime, from the urban area, with informal work, educational level of basic secondary, with a stable partner (married or in a free union), non-ethnic, (No perceived as indigenous, ROM or Afro-Colombian, were in their second or third pregnancy period, covered by IVE counseling and the psychoprophylactic course and began their prenatal care in the first trimester, and an incidence of 3,2% of EMM was estimated. Conclusions: the risk of EMM was higher in pregnant women without IVE advice, psychoprophylactic course, ultrasound, nutrition consultation, gynecology, iron sulfate, calcium or folic acid; also in adolescents, in those over 36 years of age, from rural areas, without a stable partner, ethnic, vulnerable population, primiparous, with a history of abortion, with weight/height alterations, with high obstetric risk, with Dx of HIV or gestational syphilis and with late start of prenatal care.

Introducción: La morbilidad materna extrema es un evento de interés en salud pública que tiene un impacto importante al evaluar los servicios de salud ya que una atención oportuna y de calidad en una mujer con una complicación obstétrica severa puede prevenir un desenlace fatal. En una EAPB en la ciudad de Cali durante el periodo 2019-2020 se evidencio una necesidad referente a determinar cuál es el comportamiento de los factores mayormente asociados a la morbilidad materna extrema, siendo este un estudio relevante para apoyar la toma de decisiones. Metodología: es un tipo de estudio observacional analítico de cohorte retrospectiva, se trabajó con un censo de las gestantes registradas en la matriz de seguimiento nominal de la aseguradora, que se alimenta de diversas fuentes como la base de datos única de afiliados, SIVIGILA, RIPS entre otras, se realizó una caracterización de los factores sociodemográficos, clínicos y de atención en salud  por medio de frecuencias absolutas y relativas, posteriormente se cruzaron en tablas de contingencias para determinar asociación por medio de la prueba chi cuadrado y se realizó un modelo de regresión log binomial para establecer los factores que mejor explican la Morbilidad Materna Extrema (MME). Resultados: en su mayoría las gestantes tenían entre 18 y 35 años, del régimen subsidiado, de la zona urbana, con trabajo informal, nivel educativo de básica secundaria, con pareja estable (casadas o en unión libre), no étnica, (No se perciben como indígena, ROM o afrocolombiana, cursaban su segundo o tercer periodo de gestación, con cobertura de asesoría de IVE y del curso psicoprofiláctico y iniciaron su control prenatal en el primer trimestre y se estimó una incidencia de 3,2% de MME. Conclusiones:  el riesgo de MME fue superior gestantes sin asesoría de IVE, curso psicoprofiláctico, ecografía, consulta de nutrición, ginecología, sulfato ferros, calcio o ácido fólico; además en adolescentes, en mayores de 36 años, de la zona rural, sin pareja estable, con pertenencia étnica, de población vulnerable, primigestantes, con antecedente de aborto, con alteraciones peso/talla, con alto riesgo obstétrico, con Dx de VIH o sífilis gestacional y con inicio tardío del control prenatal.

Barriers to Medication Error Reporting in a federally qualified health center (Barriers to MEET in a FQHC).

Barriers to medication error reporting in inpatient settings and primary care clinics are well known and can be categorized as psychological, logistical, knowledge, and workplace. These barriers have not been explored well at Federally Qualified Health Centers (FQHC) where limited pharmacy services may exist. METHODS: This prospective, cross-sectional study surveyed 161 medical professionals at a large FQHC clinic with a small pharmacy team to explore their understanding of medication error categories and the influence of barriers to medication error reporting on their decision to report. RESULTS: Thirty-six (22.4%) respondents completed the survey. Nearly 40% of respondents would not report a near miss error and were influenced by workplace/environmental barriers significantly more than those who would report. Regardless of reporting experience or patient-care role, assessed barrier categories influence the decision to report similarly. CONCLUSION: Near miss medication errors are inconsistently reported. Efforts to improve reporting should emphasize addressing workplace/environmental barriers.

Maternal near miss hospitalizations in the Borana Zone, Ethiopia: A facility-based longitudinal cross-sectional study.

Background: Maternal near miss refers to a woman who nearly died but survived a complication that occurred during pregnancy, childbirth, or within 42 days of pregnancy termination. While there has been considerable progress in reducing maternal mortality rates, maternal near miss cases can provide valuable insights into the quality of maternal healthcare and help identify areas for improvement. However, there is limited evidence on the factors contributing to maternal near miss cases, including health system failures, delays in care, and provider-related factors. Therefore, this study aimed to assess the incidence, causes, and factors associated with maternal near misses in public Hospitals of Borena Zone. Methods: A facility-based longitudinal cross-sectional study design was employed at four Public Hospitals in Borena Zone from August 15, 2022, to November 15, 2022, using the WHO criteria for maternal near miss event. In total, 117 participants were included in the study. Eligibility was determined using key clinical, organ dysfunction, laboratory, and management criteria, as per the WHO guidelines for near-miss events. Underlying and contributing causes of maternal near misses were documented from each participant's records. Result: There were 1421 deliveries during the study period and 117 eligible women developed potentially life-threatening conditions. Only 61 women experienced severe maternal outcomes (55 near misses and six maternal deaths). The maternal near miss incidence ratio was 38.7 per 1000 live births, with a mortality index of 9.8%. Hypertensive disorders and obstetric hemorrhage are the leading underlying causes of maternal near misses. Conclusion: The incidence of maternal near miss was remarkably high when compared to previous studies. Giving special emphasis to life-saving interventions, critical care, reducing delays and improving the referral system are critical to improve quality of care.

The Association of Job Stress, Quality of Sleep, and the Experience of Near-Miss Errors among Nurses in General Hospitals.

This study investigated the association of job stress, quality of sleep, and near-miss error experiences among nurses working in general hospitals. A convenience sample of 195 nurses with over 3 months of work experience in a general hospital participated in the study. Statistical analyses were performed using SPSS 27.0. Factors influencing experiences of near-miss errors were examined through univariable and multivariate logistic regression. In total, 58.5% of nurses in a general hospital had experienced near-miss errors. Nurses in the upper job stress tertile (≥118) were 2.24 times more likely to encounter near-miss errors (95% CI: 1.07-4.69) and particularly 2.58 times (95% CI: 1.26-5.26) in falls and medical equipment-related near-miss errors. Nurses working more than 3 h of overtime per week had a 2.72 times higher (95% CI: 1.35-5.48) likelihood of experiencing near-miss errors related to falls and medical equipment and 4.03 times higher (95% CI: 1.92-8.45) likelihood of experiencing near-miss errors associated with examination procedures. To prevent near-miss errors among nurses in general hospitals, effective management of organizational job stress is crucial. Particularly for departments with a high level of overtime work (more than 3 h/week), it is essential to provide and manage educational programs on patient safety.

The predictive power of electronic reporting system utilization on voluntary reporting of near-miss incidents among nurses: A PLS-SEM approach.

Background: Patient safety is crucial in healthcare, with incident reporting vital for identifying and addressing errors. Near-miss incidents, common yet underreported, serve as red flags requiring attention. Nurses' underreporting, influenced by views and system usability, inhibits learning opportunities. The Electronic Reporting System (ERS) is a modern solution, but its effectiveness remains unclear. Objective: This study aimed to investigate the role of the ERS in enhancing the voluntary reporting of near-miss (VRNM) incidents among nurses. Methods: A cross-sectional study was conducted in the Al Dhafra region of the United Arab Emirates, involving 247 nurses from six hospitals. Data were collected using a questionnaire between April 2022 and August 2022. Structural Equation Modelling Partial Least Square (SEM-PLS) was employed for data analysis. Results: The average variance extracted for the ERS construct was 0.754, indicating that the common factor accounted for 75.4% of the variation in the ERS scores. The mean ERS score was 4.093, with a standard deviation of 0.680. For VRNM, the mean was 4.104, and the standard deviation was 0.688. There was a positive correlation between ERS utilization and nurses' willingness to report near-miss incidents. Additionally, our research findings suggest a 66.7% relevance when applied to various hospital settings within the scope of this study. Conclusion: The findings suggest that adopting a user-friendly reporting system and adequate training on the system's features can increase reporting and improve patient safety. Additionally, these systems should be designed to be operated by nursing staff with minimal obstacles.