RESUMEN
An approach implemented within a hospital has enabled the process for reporting adverse events to be defined in its entirety. It was combined with a pedagogical approach with the teams in order to give it meaning.
Asunto(s)
Errores Médicos/prevención & control , Gestión de Riesgos , Comunicación , Humanos , Cultura Organizacional , Mejoramiento de la CalidadRESUMEN
OBJECTIVES: Evaluate the incidence of perinatal mortality and evaluate the percentage of non optimal care management of fatal pregnancies between 2005 and 2011 in the Rhone-Alpes region in France, by the use of the Aurore network. Evaluate the development of morbi-mortality revues (MMR) in this region. METHODS: Retrospective study of perinatal mortality in the Aurore network, from 2005 to 2011. Systematic analysis of care management (adapted, non adapted, non evaluable), of each perinatal death that occurred in the Aurore network, by a multidisciplinary committee during regional MMR. RESULTS: The incidence of perinatal mortality has diminished from 2005 to 2011 (8,4 vs. 6,4, P<0.07) as well as the percentage of non adapted care management (13% vs. 5,6%, P<0.001). An underestimation of irregularities in the fetal heart rate was described in 34% of per partum deaths. The percentage of optimal care management was significantly higher when the obstetrician was in the maternity rather than on call at home (P<0.03) and in type 3 maternities compared to type 1 and 2 maternities (P<0.04). The attendance of the MMR organized in the AURORE network progressed between 2006 and 2011. CONCLUSION: Since 2005, a decrease in perinatal mortality and in non-adapted care management was observed. More studies are necessary to evaluate the link between the development of MMR in this network and the amelioration of these two indicators.