Causes for Medical Errors in Obstetrics and Gynaecology
Abstract
:1. Introduction
2. Methods
2.1. Literature Search
2.2. Eligibility Criteria
2.3. Study Selection
2.4. Data Extraction
3. Results
3.1. Results of the Search and Study Selection
3.2. Quality Criteria
3.3. Included Studies
3.4. Definitions
3.5. Findings
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
Appendix A
Search Database | Search Terms | Filters | Articles (n) |
---|---|---|---|
Pubmed | Medical error, medical mistake, adverse event, risk management, health care quality assessment, health care quality, access, and evaluation, gynaecology and/or obstetrics |
| 1598 |
EMBASE | Medical error, medical mistake, adverse event, complication, risk factor, risk management, incident report, risk report, quality assurance, quality assessment, health care quality assessment, health care quality, access, and evaluation, gynaecology or obstetrics |
| 701 |
Web of knowledge | Medical error, medical mistake, adverse event, complication, risk factor, risk management, incident report, quality assurance, quality assessment, health care quality assessment |
| 2988 |
cocchrane library | Medical error, medical mistake, adverse event, risk management, health care quality assessment, health care quality, access and evaluation, gynaecology, obstetrics |
| 1003 |
Total (before exclusion) | 6290 |
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Abstractors Training | Selection Criteria | Variable Definition | Abstraction Forms | Performance Monitored | Blind to Hypothesis | IRR * Mentioned | IRR * Tested | MR Identified | Sampling Method | Missing Data Management | Institutional Review Board | Total Score | |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Aibar [13] | 1 | 1 | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | 9 |
Aikpitanyi [14] | 0 | 1 | 0 | 1 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 1 | 5 |
Benimana [15] | 0 | 1 | 1 | 1 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 1 | 6 |
Carvalho [16] | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 0 | 0 | 0 | 0 | 1 | 6 |
David [17] | 0 | 1 | 1 | 1 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 1 | 6 |
Florea [18] | No MRR, criteria inapplicable | ||||||||||||
Habte [19] | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 0 | 1 | 0 | 1 | 9 |
Hadad [20] | 1 | 1 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 5 |
Huner [21] | No MRR, criteria inapplicable | ||||||||||||
Iwuh [22] | 0 | 1 | 1 | 1 | - | - | - | - | 1 | 1 | 0 | 0 | 5 |
Jensen [23] | No MRR, criteria inapplicable | ||||||||||||
Johansen [24] | 0 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 1 | 5 |
Johansen [25] | 0 | 1 | 1 | 1 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 8 |
Kalisa [26] | 1 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 0 | 5 |
Kasahun [27] | 1 | 1 | 1 | 1 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 1 | 7 |
Kulkarni [28] | 1 | 1 | 1 | 1 | 1 | 0 | 0 | 0 | 1 | 1 | 0 | 1 | 8 |
Mahmood [29] | 0 | 1 | 0 | 1 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 0 | 4 |
Mawarti [30] | 0 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 0 | 4 |
Mulongo [31] | No MRR, criteria inapplicable | ||||||||||||
Nassoro [32] | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 1 | 3 |
Neogi [33] | 0 | 1 | 1 | 1 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 1 | 6 |
Saucedo [34] | 0 | 1 | 1 | 1 | 0 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 7 |
Sayinzoga [35] | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 0 | 3 |
Sorensen [36] | 0 | 1 | 1 | 1 | 1 | 0 | 1 | 0 | 1 | 1 | 0 | 1 | 8 |
Wasim [37] | No MRR, criteria inapplicable | ||||||||||||
Zewde [38] | 1 | 1 | 1 | 1 | 0 | 0 | 1 | 0 | 1 | 1 | 0 | 1 | 8 |
Author | Terms Used | Definition Used |
---|---|---|
Aibar [13] | Patient safety incident | Any event or circumstance that caused or could have caused unnecessary harm to a patient. |
No harm incident | Any unforeseen and unexpected event recorded in the medical record that did not cause harm to the patient but which, under different circumstances, could have been an accident or an event that, if not discovered or corrected in time, could imply problems for the patient. | |
Adverse event | Any unforeseen and unexpected accident recorded in the medical record that caused injury and/or disability and/or prolonged the hospital stay and/or led to death, which was the result of health care and not the patient’s underlying condition. | |
Aikpitanyi [14] | Maternal death | No definition provided |
Benimana [15] | Maternal near-miss | Refers to WHO criteria |
Maternal deaths | Refers to WHO criteria | |
Carvalho [16] | Three delays | Refers to WHO criteria |
David [17] | Near-miss cases | Refers to clinical criteria for identification of near-miss (e.g., eclampsia, severe hemorrhage, severe sepsis, uterine rupture and severe malaria). |
Florea [18] | Averse events | No definition provided |
Incidents | No definition provided | |
Near-misses | No definition provided | |
Habte [19] | Maternal near-miss | Refers to WHO criteria |
Haddad [20] | Severe maternal morbidity | Refers to WHO criteria |
Hüner [21] | Adverse events | A catalogue of criteria or events was developed based on international research findings from scientific studies in two project meetings and interprofessional focus groups. |
Iwuh [22] | Maternal near-miss | Refers to WHO criteria |
Jensen [23] | Adverse health outcomes | No definition provided |
Clinical performance | TeamOBS-PPH score | |
Johansen [24] | Adverse events | No definition provided |
Serious outcomes | No definition provided | |
Serious adverse events | An injury was regarded as serious when it had serious consequences on the patient’s disease or disorder; or if it caused serious pain or reduced self-realization in the short or long term | |
Johansen [25] | Serious adverse events | Three categories were described (birth asphyxia, shoulder dystocia and severe PPH) |
Adequate obstetric care | Healthcare is in accordance with clinical practice based on Norwegian national and local obstetric guidelines. | |
Kalisa [26] | Maternal near-miss | Refers to WHO criteria: a woman who almost died but survived a complication during pregnancy, childbirth or within 42 days after the termination of pregnancy. |
Severe maternal outcome | Maternal near-miss and maternal deaths combined | |
Kasahun [27] | Maternal near-miss/severe maternal morbidity | Refers to WHO criteria and states that the terms maternal near-miss and severe maternal morbidity are used interchangeably.Operational definition: maternal near-misses (severe maternal morbidity) is women who are admitted with either of the following obstetric diagnoses: severe preeclampsia, eclampsia, severe hemorrhage, dystocia (defined in the current study as uterine rupture, impending uterine rupture like prolonged labor with previous cesarean section, and emergency C/S delivery), severe anemia (<6), sepsis (puerperal sepsis, chorioamnionitis and septic abortion). |
Kulkarni [28] | Near-miss obstetric event | Refers to WHO criteria. Near-miss obstetric event concerns a woman who nearly died as a result of a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy. Clinical criteria near-miss events were defined as any near-miss event related to a specific disease entity, while management-based near-miss events and organ-system dysfunction-based near-miss events were defined according to the near-miss approach outlined by WHO. |
Mahmood [29] | Maternal deaths | No definition described |
Mawarti [30] | Maternal deaths | Refers to WHO criteria |
Maternal near-miss | Refers to WHO criteria | |
Mulongo [31] | Maternal near-miss | Refers to WHO criteria |
Nassoro [32] | Maternal deaths that occurred due to haemorrhage | No definition described |
Neogi [33] | Stillbirths | Any baby born dead after the 24th week of pregnancy. |
Saucedo [34] | Pregnancy-associated deaths | All deaths of women while pregnant or within one year of the termination of pregnancy, regardless of the cause of death. |
Sayinzoga [35] | Maternal deaths | No definition described |
Sorensen [36] | Maternal death | No definition described |
Wasim [37] | Maternal deaths | Refers to WHO criteria |
Maternal near-miss | Refers to WHO criteria | |
Zewde [38] | Severe maternal outcome | Combination of maternal deaths and maternal near-miss |
Maternal near-miss | Refers to WHO criteria |
Quality of Care Mechanism | Study | Results | Percentages |
---|---|---|---|
Patients | Iwuh [22] | Patient education (lack of information) | 6.25 |
Clinical practice | Aikpitanyi [14] | Delay in commencing treatment | 27.8 |
Benimana [15] | Diagnostic delays | 41.3 | |
Therapeutic delays | 5.8 | ||
Florea [18] | Protocol | 5.9 | |
Nursing resources | 0.2 | ||
Physician resources | 1.7 | ||
Other personnel | 0.7 | ||
Equipment/resources | 6.9 | ||
Records/results | 14.5 | ||
Staff communication | 10.0 | ||
Patient/family communication | 1.6 | ||
Delay | 1.0 | ||
Haddad [20] | Lack of trained staff | 5.1 | |
Difficulty in monitoring | 8.1 | ||
Delay in diagnosis | 5.6 | ||
Delay in starting treatment | 6.5 | ||
Delay in referral/transfer of the case | 5.2 | ||
Improper management of the case | 21.8 | ||
Iwuh [22] | Not managed at the level of care that was needed | 20.5 | |
Clinical assessment (diagnosis), Problem recognition | 4.5 | ||
Delay in referring | 0.9 | ||
Managed at inappropriate level | 0.9 | ||
Monitoring problems | 13.4 | ||
Johansen [24] | Failure in surveillance | 36 | |
Failure in diagnostics | 17 | ||
Failure in operative delivery | 8 | ||
Failure in resuscitation | 2 | ||
Sayinzoga [35] | Lack of skilled staff | ||
Insufficient diagnostic means | |||
Inadequate monitoring of labour (use of partograph) | |||
Delay in recognising the complication or administering the correct treatment | |||
Insufficient follow-up in post-operative or postpartum period | |||
No respect for asepsis | |||
Not following protocol | |||
Inadequate resuscitation | |||
Insufficient follow-up of anaesthesia induction | |||
Insufficient pre-operative preparation | |||
Poor quality of antenatal care visit | |||
Sorensen [36] | Training of staff insufficient | ||
Habte [19] | Poor birth preparedness and poor complication readiness | 85.2 | |
Johansen [25] | Delay in decision to operate | 8 | |
Delay in decision to delivery time | 20 | ||
Failure monitoring/Misinterpretation CTG | 13 | ||
Medication error | 56.2 | ||
Nasorro [32] | Delay in managing uterine atony | 17 | |
Carvalho [16] | Inadequate prenatal care: improper conduct with patient | 5 neonatal near-miss/1 death | |
Huner [21] | Peripartum therapeutic delay | 44.32 | |
Diagnostic error | 36.36 | ||
Inadequate birth position | 34.09 | ||
Medication error | 2.27 | ||
Zewde [38] | Insuffiency of medical staff | ||
Delay in making diagnosis | |||
Poor communication during referral | |||
Emergency medicine | Aikpitanyi [14] | Delay in deciding to refer patients | 5.6 |
Haddad [20] | Difficulty in communication between hospital and regulatory centre | 18.8 | |
Delay in referral/transfer | 5.2 | ||
Mahmood [29] | Failure in delay and emergency response | 42.9 | |
Delay in procedures | 28.6 | ||
Lack of policy, protocol and guidelines. | 46.4 | ||
Delay in emergency response | 33.3 | ||
Lacking knowledge and skills | 60 | ||
Failure to follow best practice | 70 | ||
Lack of recognition of seriousness. | 50 | ||
Sayinzoga [35] | delay of the ambulance to reach the health centre | ||
Nasorro [32] | Inadequate preparation in complete readiness | 17 | |
Management | Aikpitanyi [14] | Lack of skilled manpower | 11.1 |
Mahmood [29] | Inadequate access to senior clinical staff | 39.3 | |
Failure to seek supervision or help | 43.3 | ||
Sayinzoga [35] | Delay in referring the patient at high level | ||
Sorensen [36] | Staff not available | ||
Nasorro [32] | Delated referral from another facility | 26 | |
Saucedo [34] | Lack of 24/7 on-site presence of obstetrician or anesthesiologist | 5/66 28/81 obstetrician | |
13/66 37/81 anesthesiologist | |||
Zewde [38] | Unavailability of a senior obstetrician | ||
Inappropriate management | |||
Multiple referrals between health facilities | |||
Health workforce | Johansen [24] | Failure in teamwork | 14 |
Johansen [25] | Failure in cooperation between midwife and physician | 16 | |
Pharmaceuticals and medical products | Aibar [13] | Peripheral venous catheter | 86.2 |
Closed bladder catheter | 18.9 | ||
Aikpitanyi [14] | Non-availability of blood products | 33.3 | |
Lack of essential emergency drugs | 11.1 | ||
Benimana [15] | Delayed or lacking supplies (blood and medication) | 5.8 | |
Haddad [20] | Lack of medication | 1.8 | |
Absence of blood products | 1.3 | ||
Johansen [24] | Failure in administration of medication | 11.1 | |
Sayinzoga [35] | Lack of isogroup blood | ||
Wasim [37] | Inadequacy in blood arrangement | ||
Zewde [38] | Lack of supplies and equipment | ||
Health Facilities | Aikpitanyi [14] | Non-functional ICU | 11.1 |
Carvalho [16] | Inadequate prenatal care: difficult access due to lack of specialised services | 46.5 | |
Mulongo [31] | Lack of continuity of care and coordination | ||
Wasim [37] | Inadequacy in overburdened ICU | ||
Information Systems | Iwuh [22] | Incomplete registration (lack of information) | 6.3 |
Johanssen [24] | Failure in documentation | 5 | |
Huner [21] | Lack of documentation |
Protocols | Delay | Equipment and Staff | Communication | ||||||
---|---|---|---|---|---|---|---|---|---|
Presence of Adequate Protocol | Not Following Protocol | Delay in Referral/Transfer | Delay in Diagnostics | Delay in Decision-Making/Therapy | Lack of Equipment | Lack of (Well Trained) Staff | Verbal | Medical File | |
Individual healthcare worker | 5.9% [18] 70% [24] | 0.9% [21] 5.2% [20] 5.6% [14] 26% [32] | 4.5% [22] 13.7% [20] 17% [25] 36.4% [21] 41.3% [15] | 5.8% [15] 6.5% [20] 27.8% [14] 28.6% [20] 33.3% [29] 44.3% [21] 46.0% [24] 48% [25] 61% [32] | 13% [32] 18.2% [21] 56% [25] 60% [29] | 1.6% [18] 6.25% [22] | 5% [24] 6.3% [22] | ||
Teamwork | 14% [24] 39% [25] 43.3% [29] | 10% [18] | |||||||
System | 46.4% [29] | 42.9% [29] | 6.9% [18] 55.5% [14] 5.8% [15] 3.1% [20] | 2.6% [18] 5.1% [20] 11.1% [14] 28% [34] 39.3% [29] | 18.8% [20] | 14.5% [18] |
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Share and Cite
Klemann, D.; Rijkx, M.; Mertens, H.; van Merode, F.; Klein, D. Causes for Medical Errors in Obstetrics and Gynaecology. Healthcare 2023, 11, 1636. https://doi.org/10.3390/healthcare11111636
Klemann D, Rijkx M, Mertens H, van Merode F, Klein D. Causes for Medical Errors in Obstetrics and Gynaecology. Healthcare. 2023; 11(11):1636. https://doi.org/10.3390/healthcare11111636
Chicago/Turabian StyleKlemann, Désirée, Maud Rijkx, Helen Mertens, Frits van Merode, and Dorthe Klein. 2023. "Causes for Medical Errors in Obstetrics and Gynaecology" Healthcare 11, no. 11: 1636. https://doi.org/10.3390/healthcare11111636