Shoulder dystocia documentation: an evaluation of a documentation training intervention.

OBJECTIVE: To evaluate the quality and content of nurse and physician shoulder dystocia delivery documentation before and after MORE training in shoulder dystocia management skills and documentation. METHODS: Approximately 384 charts at the Ottawa Hospital General Campus involving a diagnosis of shoulder dystocia between the years of 2000 and 2006 excluding the training year of 2003 were identified. The charts were evaluated for 14 key components derived from a validated instrument. The delivery notes were then scored based on these components by 2 separate investigators who were blinded to delivery note author, date, and patient identification to further quantify delivery record quality. RESULTS: Approximately 346 charts were reviewed for physician and nurse delivery documentation. The average score for physician notes was 6 (maximum possible score of 14) both before and after the training intervention. The nurses' average score was 5 before and after the training intervention. CONCLUSIONS: Negligible improvement was observed in the content and quality of shoulder dystocia documentation before and after nurse and physician training.

A prospective study of the efficiency of the "code 333" process at the Ottawa hospital.

OBJECTIVE: This study evaluated the efficiency of the "Code 333" process at The Ottawa Hospital (TOH) during obstetric emergencies. A Code 333 is an overhead call made in TOH obstetrics units to activate an emergency response system. The code calls for resuscitative measures on a mother and/or a fetus and expedited delivery of a fetus considered at high risk of demise. Internationally, the recommended maximum time between the decision to deliver and actual delivery of an infant, referred to as decision-to-delivery interval (DDI), is 30 minutes. METHODS: The study was conducted over an 11-month period from February 2007 to January 2008 at The Ottawa Hospital Birthing Units (TOHBU)-Civic and General campuses. Data were collected during the code using validated documentation sheets. The day and time of decision, the indication and outcome of the code, the mode of anaesthesia used, and the condition of the baby at birth were recorded for time interval calculations. RESULTS: The median DDI for 85 emergency Caesarean sections was 16 minutes. Ninety-eight percent of TOH deliveries were completed within the recommended 30 minutes. Over one third of these deliveries were completed within 15 minutes. Urgent codes had a median DDI of 13 minutes, compared with 20 minutes for less urgent codes. Time of day or day of the week did not have any effect on DDI. CONCLUSION: The recommended DDI of 30 minutes was routinely achieved at TOHBU. DDI was prolonged in only 2% of codes during the study period, with no adverse outcome.

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.

Placenta previa: its relationship with race and the country of origin among Asian women.

OBJECTIVES: To examine the association between placenta previa with maternal race and its variations by country of origin among Asian women. STUDY DESIGN: Retrospective cohort study. METHODS: We analyzed data from a population-based retrospective cohort study of 16,751,627 pregnancies in the US. The data were derived from the national linked birth/infant mortality database for the period 1995-2000. Multiple logistic regressions were used to describe the relationship between placenta previa and race as well as country of origin among Asian women. RESULTS: About 3.3 per 1,000 pregnancies were complicated with placenta previa among white women, while the corresponding figures for black women and women of other races were 3.0 and 4.5 per 1,000 pregnancies, respectively. The excess risk remained substantial and significant after adjustment for confounders for women of other races compared to white women. The frequencies of placenta previa among Chinese, Japanese, Filipino, Asian Indian, Korean, Vietnamese and other Asian or Pacific Islander were 5.6, 5.1, 7.6, 4.5, 5.9, 4.4 and 4.4 per 1,000 pregnancies, respectively. The adjusted odds ratios ranged from 1.39 to 2.15 among Asian women by country of origin, with the lowest for Japanese and Vietnamese and the highest for Filipino women in our study. CONCLUSION: Asian women have excess risk of placenta previa compared with white women. Major variation exists in placenta previa risk among Asian women, with the lowest risk in Japanese and Vietnamese women and the highest risk in Filipino women.

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.

Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital.

BACKGROUND: Adverse events are poor patient outcomes that are due to medical care. Studies of hospital patients have demonstrated that adverse events are common, but few data describe the timing of them in relation to hospital admission. We evaluated characteristics of adverse events affecting patients admitted to a Canadian teaching hospital, paying particular attention to timing. METHODS: We randomly selected 502 adults admitted to the Ottawa Hospital for acute care of nonpsychiatric illnesses over a 1-year period. Charts were reviewed in 2 stages. If an adverse event was judged to have occurred, a physician determined whether it occurred before or during the index hospitalization. The reviewer also rated the preventability, severity and type of each adverse event. RESULTS: Of the 64 patients with an adverse event (incidence 12.7%, 95% confidence interval [CI] 10.1%-16.0%), 24 had a preventable event (4.8%, 95% CI 3.2%-7.0%), and 3 (0.6%, 95% CI 0.2%-1.7%) died because of an adverse event. Most adverse events were due to drug treatment, operative complications or nosocomial infections. Of the 64 patients, 39 (61%, 95% CI 49%-72%) experienced the adverse event before the index hospitalization. INTERPRETATION: Adverse events were common in this study. However, only one-third were deemed avoidable, and most occurred before the hospitalization. Interventions to improve safety must address ambulatory care as well as hospital-based care.