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.
Aust N Z J Obstet Gynaecol
; 2024 Jun 11.
Article
en En
| MEDLINE
| ID: mdl-38863173
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 ANDMETHODS:
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.
Texto completo:
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Colección:
01-internacional
Base de datos:
MEDLINE
Idioma:
En
Revista:
Aust N Z J Obstet Gynaecol
Año:
2024
Tipo del documento:
Article
País de afiliación:
Nueva Zelanda
Pais de publicación:
Australia