Beyond the numbers: Classifying contributory factors and potentially avoidable adverse events in the gynaecology service of National Women's Health at Auckland District Health Board.

IF 1.4 4区 医学 Q3 OBSTETRICS & GYNECOLOGY
Ahalya Sathiyaselvan, Mahesh Harilall, Ines Blaj, Lois Eva, Cynthia Farquhar
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引用次数: 0

Abstract

Background: Adverse events (AEs) during health care are common and may have long-term consequences for patients. Although there is a tradition of reviewing morbidity and mortality in gynaecology, there is no recommended system for reporting contributory factors and potential avoidability.

Aims: To identify factors that contributed to AEs in the gynaecology service at National Women's Health at Auckland District Health Board and to determine potential avoidability, with the use of a multidisciplinary morbidity review.

Materials and methods: Contributory factors from a review of AEs in gynaecology services were identified and classified as organisational and/or management factors, personnel factors and barriers to patients accessing and engaging with care. Potential avoidability of the AE was also considered. A descriptive analysis of the morbidity review of patients who had an AE from 2019 to 2022 was undertaken.

Results: One hundred and fifty-three cases of AEs were reviewed and 77 (50.3%) were associated with contributory factors. Of all cases, 45 (29.4%) had organisational factors, 54 (35.3%) had personnel factors and patient factors resulting in barriers to care contributing to 11 (7.2%) cases. Sixty-five cases (42.5%) were classified as potentially avoidable. Of these 65 cases, 38 (58.5%) had organisational factors, 48 (73.8%) had personnel factors and nine (13.9%) had barriers to care.

Conclusions: The AE review process reported 50.3% of AEs had contributory factors that were classified as organisational, personnel and barriers to patients accessing care and that 42.5% of the AEs were potentially avoidable. These reviews can be used for making recommendations that potentially lead to improvements in gynaecology.

数字之外:奥克兰地区卫生局全国妇女健康中心妇科服务中可促成因素和潜在可避免不良事件的分类。
背景:医疗过程中的不良事件(AEs)很常见,并可能对患者造成长期影响。尽管妇科有审查发病率和死亡率的传统,但目前还没有推荐用于报告促成因素和潜在可避免性的系统。目的:通过使用多学科发病率审查,确定导致奥克兰地区卫生局全国妇女健康中心妇科服务中不良事件的因素,并确定潜在的可避免性:从对妇科服务中发生的意外伤害的审查中确定了促成因素,并将其归类为组织和/或管理因素、人员因素以及患者获得和参与护理的障碍。同时还考虑了意外伤害的潜在可避免性。对2019年至2022年发生AE的患者的发病率回顾进行了描述性分析:回顾了 153 例 AE,其中 77 例(50.3%)与促成因素有关。在所有病例中,45例(29.4%)与组织因素有关,54例(35.3%)与人员因素有关,11例(7.2%)与患者因素导致的护理障碍有关。65例(42.5%)被归类为潜在可避免病例。在这65例中,38例(58.5%)与组织因素有关,48例(73.8%)与人员因素有关,9例(13.9%)与护理障碍有关:意外事故审查过程显示,50.3%的意外事故有组织、人员和患者获得护理的障碍等促成因素,42.5%的意外事故可能是可以避免的。这些审查可用于提出建议,从而改善妇科服务。
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来源期刊
CiteScore
3.40
自引率
11.80%
发文量
165
审稿时长
4-8 weeks
期刊介绍: The Australian and New Zealand Journal of Obstetrics and Gynaecology (ANZJOG) is an editorially independent publication owned by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and the RANZCOG Research foundation. ANZJOG aims to provide a medium for the publication of original contributions to clinical practice and/or research in all fields of obstetrics and gynaecology and related disciplines. Articles are peer reviewed by clinicians or researchers expert in the field of the submitted work. From time to time the journal will also publish printed abstracts from the RANZCOG Annual Scientific Meeting and meetings of relevant special interest groups, where the accepted abstracts have undergone the journals peer review acceptance process.
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