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.

Autor: Sathiyaselvan A; National Women's Health, Te Toka Tumai, Te Whatu Ora, Auckland, New Zealand., Harilall M; National Women's Health, Te Toka Tumai, Te Whatu Ora, Auckland, New Zealand., Blaj I; National Women's Health, Te Toka Tumai, Te Whatu Ora, Auckland, New Zealand., Eva L; National Women's Health, Te Toka Tumai, Te Whatu Ora, Auckland, New Zealand., Farquhar C; Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand.
Jazyk: angličtina
Zdroj: The Australian & New Zealand journal of obstetrics & gynaecology [Aust N Z J Obstet Gynaecol] 2024 Jun 11. Date of Electronic Publication: 2024 Jun 11.
DOI: 10.1111/ajo.13844
Abstrakt: 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.
(© 2024 The Author(s). Australian and New Zealand Journal of Obstetrics and Gynaecology published by John Wiley & Sons Australia, Ltd on behalf of Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)
Databáze: MEDLINE
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