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An evaluation by the Norwegian Health Care Supervision Authorities of events involving death or injuries in maternity care

INTRODUCTION: We aimed to determine how serious adverse events in obstetrics were assessed by supervision authorities. MATERIAL AND METHODS: We selected cases investigated by supervision authorities during 2009‐2013. We analyzed information about who reported the event, the outcomes of the mother an...

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Detalles Bibliográficos
Autores principales: Johansen, Lars Thomas, Braut, Geir Sverre, Andresen, Jan Fredrik, Øian, Pål
Formato: Online Artículo Texto
Lenguaje:English
Publicado: John Wiley and Sons Inc. 2018
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6175322/
https://www.ncbi.nlm.nih.gov/pubmed/29806955
http://dx.doi.org/10.1111/aogs.13391
Descripción
Sumario:INTRODUCTION: We aimed to determine how serious adverse events in obstetrics were assessed by supervision authorities. MATERIAL AND METHODS: We selected cases investigated by supervision authorities during 2009‐2013. We analyzed information about who reported the event, the outcomes of the mother and infant, and whether events resulted from errors at the individual or system level. We also assessed whether the injuries could have been avoided. RESULTS: During the study period, there were 303 034 births in Norway, and supervision authorities investigated 338 adverse events in obstetric care. Of these, we studied 207 cases that involved a serious outcome for mother or infant. Five mothers (2.4%) and 88 infants (42.5%) died. Of the 207 events reported to the supervision authorities, patients or relatives reported 65.2%, hospitals reported 39.1%, and others reported 4.3%. In 8.7% of cases, events were reported by more than 1 source. The supervision authority assessments showed that 48.3% of the reported cases involved serious errors in the provision of health care, and a system error was the most common cause. We found that supervision authorities investigated significantly more events in small and medium‐sized maternity units than in large units. Eighteen health personnel received reactions; 15 were given a warning, and 3 had their authority limited. We determined that 45.9% of the events were avoidable. CONCLUSIONS: The supervision authorities investigated 1 in 1000 births, mainly in response to complaints issued from patients or relatives. System errors were the most common cause of deficiencies in maternity care.