[Adverse events related to care in obstetric units]

Bente Kristin Johansen, Brynhild Braut, Petter Schou
Tidsskrift for Den Norske Lægeforening: Tidsskrift for Praktisk Medicin, Ny Række 2007 October 18, 127 (20): 2670-2

BACKGROUND: The aim of the present investigation was to uncover whether adverse events related to care in obstetric units have been preceded by specific health care conditions, and whether such causal relations could be classified into general categories.

MATERIAL AND METHOD: The data cover 47 supervision cases within the area of pregnancy--and birth care. The cases were handled by the Norwegian Board of Health centrally (n = 32) and the Norwegian Board of Health in the counties (n = 15) in the period 2003-2006.

RESULTS: Several conditions caused the adverse events. They could be classified into the four main categories: communication--and cooperation failure, uncertain lines of responsibility, lack of qualification, and weaknesses in the organization. The examination of the material disclosed that at least 2/3 of the adverse event causes could be traced back to organization of the facility and uncertain lines of responsibility.

INTERPRETATION: The causes of adverse events in obstetric units are often due to circumstances over which the individual health care personnel had no control. The classification of causes into four main categories can be used as a supplement tool in the internal improvement process at departments of obstetrics.

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