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LEARNING FROM ADVERSE OUTCOMES: A SYSTEM FOR IDENTIFICATION AND ASSESSMENT OF SEVERE MATERNAL MORBIDITY

Part of: Bespoke shallow archive Weizmann

Published online by Cambridge University Press:  01 May 2007

V BRACE  and
G PENNEY
V BRACE*
Affiliation:
Aberdeen Maternity Hospital, United Kingdom.
G PENNEY
Affiliation:
Scottish Programme for Clinical Effectiveness in Reproductive Health, Aberdeen, United Kingdon
*
*V Brace, Aberdeen Maternity Hospital, Cornhill Road, Aberdeen, AB25 2NR.
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Extract

Traditionally, the maternal mortality ratio has been used as a measure of the quality of maternity care and review of individual cases of maternal death has provided information for professional learning in order to improve patient care. In the United Kingdom, this process of multidisciplinary review has been carried out for over 50 years in the form of the Confidential Enquiry into Maternal Deaths (CEMD). The Confidential Enquiry is well respected internationally and has been used as a model for confidential enquiries in other countries, such as South Africa.

Type
Research Article
Information
Fetal and Maternal Medicine Review , Volume 18 , Issue 2 , May 2007 , pp. 121 - 144
Copyright
Copyright © Cambridge University Press 2007

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References

REFERENCES

1Mahutte, NG, Murphy-Kaulbeck, L, Le, Q, Soloman, J, Benjamin, A, Boyd, ME. Obstetric admissions to the intensive care unit. Obstet Intens Care 1999; 94: 263–66.Google ScholarPubMed
2Mantel, GD, Buchmann, E, Rees, H, Pattinson, RC. Severe acute maternal morbidity: a pilot study of a definition for a near-miss. Br J Obstet Gynaecol 1998; 105: 985–90.Google Scholar
3Drife, JO. Maternal “near miss” reports? Br Med J 1993; 307: 1087–1088.CrossRefGoogle ScholarPubMed
4Vandecruys, HIB, Pattinson, RC, Macdonald, AP, Mantel, GD. Severe acute maternal morbidity and mortality in the Pretoria academic complex: changing patterns over 4 years. Eur J Obstet Gynecol Reprod Biol 2002; 102: 6–10.Google Scholar
5Pattinson, RC, Hall, M. Near misses: a useful adjunct to maternal death enquiries. Br Med Bull 2003; 67: 231–43.CrossRefGoogle ScholarPubMed
6Baskett, TF, Sternadel, J. Maternal intensive care and near-miss mortality in obstetrics. Br J Obstet Gynaecol 1998; 105: 981–84.CrossRefGoogle ScholarPubMed
7Stones, W, Lim, W, Farook, A, Kelly, M. An investigation of maternal morbidity with the identification of life-threatening “near-miss” episodes. Health Trends 1991; 23: 13–15.Google Scholar
8Duffy, S, Gaffney, G. Maternal admissions to ICU – time to re-evaluate. Ir Med J 2001; 94: 248–49.Google Scholar
9Vincent, C, Taylor-Adams, SE, Chapman, EJ, Hewett, D, Prior, S, Strange, P et al. How to investigate and analyse clinical incidents: Clinical Risk Unit and Association of Litigation and Risk Management protocol. Br Med J 2000; 320: 777–81.Google Scholar
10Vincent, C, Adams, S, Chapman, J, Hewett, D, Prior, S, Strange, P, et al. A protocol for the investigation and analysis of clinical incidents. London: The Royal Society of Medicine Press; 1999. p. 1–54.Google Scholar
11Neale, G, Woloshyowych, M, Vincent, C. Exploring the causes of adverse events in NHS hospital practice. J R Soc Med 2001; 94: 322–30.Google Scholar
12Brennan, TA, Leape, LL, Laird, NM, Hebert, L, Localio, AR, Lawthers, AG et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324: 370–76.Google Scholar
13 To err is human: building a safer health system. Kohn, LT, Corrigan, JM, Donaldson, MS (eds). Washington, DC: National Academic Press; 2000; p. 1–287.Google Scholar
14Gawande, AA, Thomas, EJ, Zinner, MJ, Brennan, TA. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery 1999; 126: 66–75.CrossRefGoogle ScholarPubMed
15Wilson, RM, Runican, WB, Gibberd, RW, Harrison, BT, Newby, L, Hamilton, JD. The quality in Australian healthcare study. Med J Aust 1995; 163: 458–71.CrossRefGoogle Scholar
16Vincent, C, Neale, G, Woloshyowych, M. Adverse events in British hospitals: prelimary retrospective record review. Br Med J 2001; 322: 517–19.Google Scholar
17Expert group chaired by the Chief Medical Officer. An organisation with a memory. London: The Stationery Office; 2000. p. xiv–92.Google Scholar
18Milne, JK. Managing risk, clinical error, and quality of care. J Obstet Gynaecol Can 2002; 24: 717–20.Google Scholar
19Walshe, K. The development of clinical risk management. In: Vincent, C (ed). Clinical Risk Management. Enhancing patient safety. London: BMJ Books; 2001; p. 45–60.Google Scholar
20Penney, GC, Mathers, AM. Clinical risk management for obstetricians and gynaecologists. London: RCOG; 2001 p. 1–6.Google Scholar
21Reason, JT. Understanding adverse events: the human factor. In: Vincent, C (ed). Clinical risk management. Enhancing patient safety. London: BMJ Publishing Group; 2001. p. 9–30.Google Scholar
22 Clinical Governance. London: RCOG; 1999.Google Scholar
23 A first class service: quality in the new NHS. London: Department of Health; 1998. p. 1–98.Google Scholar
24Department of Health. Building a safer NHS for patients. (Implementing an organisation with a memory). London: Crown; 2001. p. 1–66.Google Scholar
25Woolf, SH, Kuzel, AJ, Dovey, SM, Phillips, RL. A string of mistakes: the importance of cascade analysis in describing, counting, and preventing medical errors. Ann Fam Med 2004; 2: 317–26.Google Scholar
26Reason, J. Human error: models and management. Br Med J 2000; 320: 768–70.Google Scholar
27Carroll, JS, Rudolph, JW, Hatakenaka, S. Lessons learned from non-medical industries: root cause analysis as culture change at a chemical plant. Qual Saf Health Care 2002; 11: 266–69.Google Scholar
28Vincent, C. Understanding and responding to adverse events. N Engl J Med 2003; 348: 1051–56.Google Scholar
29Sheikh, A, Hurwitz, B. Log of errors is needed. Br Med J 2000; 321: 505.Google ScholarPubMed
30Ashcroft, B, Eistein, M, Boreham, N. Systems approach to intrapartum risk management is important. Br Med J 2000; 321: 508.Google Scholar
31Tasker, RC. Training and dealing with errors or mistakes in medical practical procedures. Arch Dis Child 2000; 83: 95–98.Google Scholar
32Wolff, AM, Bourke, J. Detecting and reducing adverse events in an Australian rural base hospital emergency department using medical record screening and review. Emerg Med J 2002; 19: 35–40.Google Scholar
33White, AA, Pichert, JW, Bledsoe, SH, Irwin, C, Entman, SS. Cause and effect analysis of closed claims in obstetrics and gynecology. Obstet Gynecol 2005; 105: 1031–38.Google Scholar
34Helmreich, RL. On error management: lessons from aviation. Br Med J 2000; 320: 781–85.Google Scholar
35Cohen, MR. Why error reporting systems should be voluntary. Br Med J 2000; 320: 728–29.Google Scholar
36Leape, LL. Why should we report adverse incidents? J Eval Clin Pract 1999; 5: 1–4.Google Scholar
37Stanhope, N, Crowley-Murphy, M, Vincent, C, O'Connor, AM, Taylor-Adams, SE. An evaluation of adverse incident reporting. J Eval Clin Pract 1999; 5: 5–12.Google Scholar
38Vincent, C, Stanhope, N, Crowley-Murphy, M. Reasons for not reporting adverse incidents: an empirical study. J Eval Clin Pract 1999; 5: 13–21.Google Scholar
39Error reporting systems. In: Kohn, LT, Corrigan, JM, Donaldson, MS (eds). To err is human: building a safer health system. Washington, D.C.: National Academic Press; 2004. p. 86–108.Google Scholar
40Connolly, CK. Relation between reported mishaps and safety is unclear. Br Med J 2000; 321: 505–506.Google ScholarPubMed
41Wilson, T, Pringle, M, Sheikh, A. Promoting patient safety in primary care. Br Med J 2001; 323: 583–84.CrossRefGoogle ScholarPubMed
42Secker-Walker, J, Taylor-Adams, S. Clinical incident reporting. In: Vincent, C (ed). Clinical risk management. Enhancing patient safety. London: BMJ Publishing Group; 2001. p. 419–38.Google Scholar
43Bero, LA, Grilli, R, Grimshaw, JM, Harvey, E, Oxman, AD, Thomson, MA et al. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. Br Med J 1998; 317: 465–68.CrossRefGoogle Scholar
44Jamtvedt, G, Young, JM, Kristoffersen, DT, Tomson O'Brien, MA, Oxman, AD. Audit and feedback: effects on professional practice and healthcare outcomes. The Cochrane Database of Systematic Reviews 2003(Issue 3).Google Scholar
45McQuillan, P, Pilkington, S, Allan, A, Taylor, B, Short, A, Morgan, G et al. Confidential inquiry into quality of care before admission to intensive care. Br Med J 1998; 316: 1853–58.CrossRefGoogle ScholarPubMed
46Lewis, G, Drife, J, Clutton-Brock, T, Cooper, G, Hall, M, Harper, M et al. Why Mothers Die 2000–2002. Confidential Enquiry into Maternal and Child Health. London: RCOG Press; 2004. p. 1–326.Google Scholar
47 Report of the RCOG working party on prophylaxis against thromboembolism in gynaecology and obstetrics. London: RCOG Press; 1995; p. 5–31.Google Scholar
48Callum, JL, Merkley, LL, Coovadia, AS, Lima, AP, Kaplan, HS. Experience with medical event reporting system for transfusion medicine (MERS-TM) at three hospitals. Transfus Apher Sci 2004; 31: 133–43.Google Scholar
49Thomas, AN, Pilkington, CE, Greer, E. Critical incident reporting in UK intensive care units: a postal survey. J Eval Clin Pract 2003; 9: 59–68.Google Scholar
50Pattinson, RC, Say, L, Makin, JD, Bastos, MH. Critical incident audit and feedback to improve perinatal and maternal mortality and morbidity [Review]. Cochrane Database of Systematic Reviews 4:CD002961. 2005.Google Scholar
51Wagaarachchi, PT, Graham, WJ, Penney, GC, McCaw-Binns, A, Yeboah, AK, Hall, MH. Holding up a mirror: changing obstetric practice through criterion-based clinical audit in developing countries. Int J Gynaecol Obstet 2001; 74: 119–30.Google Scholar
52Lewis, G. Beyond the numbers: reviewing maternal deaths and complication to make pregnancy safer. Br Med Bull 2003; 67: 27–37.Google Scholar
53Loudon, I. Maternal mortality in the past and its relevance to developing countries today. Am J Clin Nutr 2000; 72: 241S–6S.CrossRefGoogle ScholarPubMed
54 Achievements in public health, 1990–1999: healthier mothers and babies. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. www.cdc.gov/mmwr//preview/mmwrhtml/mm4838a2.htm [Accessed 31/03/03]Google Scholar
55Kilpatrick, SJ, Crabtree, KE, Kemp, A, Geller, S. Preventability of maternal deaths: comparison between Zambian and American referral hospitals. Obstet Gynecol 2002; 100: 321–26.Google Scholar
56National Committee for the Confidential Enquiry into Maternal Deaths. Interim report on the confidential enquiry into maternal deaths in South Africa. 1998; p. 1–21 http://196.36.153.56/doh/docs/reports/1998/mat_deaths.htmlGoogle Scholar
57Songane, FF, Bergstrom, S. Quality of registration of maternal deaths in Mozambique: a community-based study in rural and urban areas. Soc Sci Med 2002; 54: 23–31.Google Scholar
58Khosla, AH, Dahiya, K, Sangwan, K. Maternal mortality and ‘near-miss’ in rural north India. Int J Gynaecol Obstet 2000; 68: 163–64.Google Scholar
59Mantel, GD, Moodley, J. Can a developed country's maternal mortality review be used as the ‘gold standard’ for a developing country? Eur J Obstet Gynecol Reprod Biol 2002; 100: 189–95.CrossRefGoogle ScholarPubMed
60Lewis, G, Drife, JO, Botting, B, Carson, C, Cooper, G, Hall, M et al. Why Mothers Die 1997–1999. Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG Press; 2001. p. v–365.Google Scholar
61Pattinson, RC, Buchmann, E, Mantel, G, Schoon, M, Rees, H. Can enquires into severe maternal morbidity act as a surrogate for maternal death enquires? Br J Obstet Gynaecol 2003; 110: 889–93.Google Scholar
62Waterstone, M, Bewley, S, Wolfe, C. Incidence and predictors of severe obstetric morbidity: case-control study. Br Med J 2001; 322: 1089–93.Google Scholar
63Panchal, S, Arria, AM, Harris, AP. Intensive care utilization during hospital admission for delivery: prevalence, risk factors, and outcomes in a statewide population. Anesthesiology 2000; 92: 1537–44.Google Scholar
64Prual, A, Bouvier-Colle, M-H, De Bernis, L, Breart, G. Severe maternal morbidity from direct obstetric causes in West Africa: incidence and case fatality rates. Bull WHO 2000; 78: 593–602.Google Scholar
65Filippi, V, Ronsmans, C, Gandaho, T, Graham, W, Alihonou, E, Santos, P. Women's reports of severe (near-miss) obstetric complications in Benin. Stud Fam Plann 2000; 31: 309–24.Google Scholar
66Weeks, A, Lavender, T, Nazziwa, E, Mirembe, F. Personal accounts of ‘near-miss’ maternal mortalities in Kampala, Uganda. BJOG 2005; 112: 1302–307.Google Scholar
67Nashef, S. What is a near miss? Lancet 2003; 361: 180–81.Google Scholar
68Murphy, DJ, Charlett, P. Cohort study of near-miss maternal mortality and subsequent reproductive outcome. Eur J Obstet Gynecol Reprod Biol 2002; 102: 173–78.Google Scholar
69Gellar, SE, Rosenburg, D, Cox, SM, Kilpatrick, S. Defining a conceptual framework for near-miss maternal morbidity. JAMA 2002; 57: 135–39.Google Scholar
70Tripathi, R, Rathmore, AM, Saran, S. Intensive care for critically ill obstetric patients. Int J Gynaecol Obstet 2000; 68: 257–58.CrossRefGoogle ScholarPubMed
71Bouvier-Colle, M-H, Salanave, B, Ancel, P-Y, Varnoux, N, Ferandez, H, Papiernik, E et al. Obstetric patients treated in intensive care units and maternal mortality. Eur J Obstet Gynecol Reprod Biol 1996; 65: 121–25.Google Scholar
72Okafor, UV, Aniebue, U. Admission pattern and outcome in critical care obstetric patients. Int J Obstet Anesth 2004; 13: 164–66.Google Scholar
73Baskett, TF, O'Connell, CM. Severe obstetric maternal morbidity: a 15-year population-based study. J Obstet Gynaecol 2005; 25: 7–9.Google Scholar
74Ancel, P-Y, Bouvier-Colle, M-H, Breart, G, Varnoux, N, Salanave, B, and the study group of the maternal morbidity. Risk factors for maternal condition at admission to an intensive care unit: does health care organisation play a role? J Perinat Med 1998; 26: 354–64.Google Scholar
75Brace, V, Hall, M, Penney, G. Quantifying severe maternal morbidity: a Scottish population study. BJOG 2004; 111: 481–84.Google Scholar
76Baskett, TF. Emergency obstetric hysterectomy. J Obstet Gynaecol 2003; 23: 353–55.Google Scholar
77Kwee, A, Bots, ML, Visser, GHA, Bruinse, HW. Emergency peripartum hysterectomy: a prospective study in the Netherlands. Eur J Obstet Gynecol Reprod Biol 2006; 124: 187–92.Google Scholar
78Zhang, W-H, Alexander, S, Bouvier-Colle, M-H, Macfarlane, A, the MOMS-B Group. Incidence of severe pre-eclampsia, postpartum haemorrhage and sepsis as a surrogate marker for severe maternal morbidity in a European population-based study: the MOMS-B survey. BJOG 2005; 112: 89–96.Google Scholar
79Scottish Obstetric Guidelines and Audit Project. The management of postpartum haemorrhage. Aberdeen: Scottish Programme for Clinical Effectiveness in Reproductive Health; 1998; p. 1–24.Google Scholar
80Stones, RW, Paterson, CM, Saunders, NJ. Risk factors for major obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol 1993; 48: 15–18.Google Scholar
81Hayashi, RH. Hemorrhagic shock in obstetrics. Crit Care Obstet 1986; 13: 755–63.Google Scholar
82Lédée, N, Ville, Y, Musset, D, Mercier, F, Frydman, R, Ferandez, H. Management in intractable obstetric haemorrhage: an audit study on 61 cases. Eur J Obstet Gynecol Reprod Biol 2001; 94: 189–96.Google Scholar
83Bonnar, J. Massive obstetric haemorrhage. Best Pract Res Clin Obstet Gynaecol 2000; 14: 1–18.Google Scholar
84Schuurmans, N, MacKinnon, C, Lane, C, Etches, D. Prevention and management of postpartum haemorrhage. J SOGC 2000; 22: 271–81.Google Scholar
85Bell, JS, Campbell, DM, Graham, WJ, Penney, GC, Ryan, M, Hall, MH. Do obstetric complications explain high caesarean section rates among women over 30? A retrospective analysis. Br Med J 2001; 322: 894–95.CrossRefGoogle ScholarPubMed
86Wen, SW, Huang, L, Liston, R, Heaman, M, Baskett, T, Rusen, ID et al. Severe maternal morbidity in Canada, 1991–2001. Can Med Assoc J 2005; 173: 759–63.Google Scholar
87Rangasami, JJ, Greenwood, DC, McSporran, B, Smail, PJ, Patterson, CC, Waugh, NR. Rising incidence of type 1 diabetes in Scottish children, 1984–93. Arch Dis Child 1997; 77: 210–13.Google Scholar
88Ford, HL, Gerry, E, Airey, CM, Vail, A, Johnson, MH, Williams, DRR. The prevalence of multiple sclerosis in the Leeds Health Authority. J Neurol Neurosurg Psychiatry 1998; 64: 605–10.Google Scholar
89Morris, AD, Boyle, DIR, MacAlpine, R, Esmile-Smith, A, Jung, RT, Newton, RW et al. The diabetes audit and research in Tayside Scotland (darts) study: electronic record linkage to create a diabetes register. Br Med J 1997; 315: 524–28.Google Scholar
90Gilbert, TT, Smulian, JC, Martin, AA, Ananth, CV, Scorza, W, Scardella, AT et al. Obstetric admissions to the intensive care unit: outcomes and severity of illness. Obstet Gynecol 2003; 102: 897–903.Google Scholar
91Murphy, DJ. Commentary: Obstetric morbidity data and the need to evaluate thromboembolic disease. Br Med J 2001; 322: 1093–94.Google Scholar
92Keizer, JL, Zwart, JJ, Meerman, RH, Harinck, BIJ, Feuth, HDM, van Roosmalen, J. Obstetric intensive care admissions: a 12-year review in a tertiary care centre. Eur J Obstet Gynecol Reprod Biol 2006; 128: 152–56.Google Scholar
93Selo-Ojeme, DO, Omosaiye, M, Battacharjee, P, Kadir, RA. Risk factors for obstetric admissions to the intensive care unit in a tertiary hospital: a case-control study. Arch Gynaecol Obstet 2005; 272: 207–10.Google Scholar
94Filippi, V, Ronsmans, C, Gohou, V, Goufodji, S, Lardi, M, Sahel, A et al. Maternity wards or emergency obstetric rooms? Incidence of near-miss events in African hospitals. Acta Obstet Gynecol Scand 2005; 84: 11–16.Google Scholar
95Gellar, SE, Rosenberg, D, Cox, S, Brown, M, Simonson, L, Kilpatrick, S. A scoring system identified near-miss maternal morbidity during pregnancy. J Clin Epidemiol 2004; 57: 716–20.Google Scholar
96Filippi, V, Alihonou, E, Mukantaganda, S, Graham, WJ, Ronsmans, C. Near misses: maternal morbidity and mortality. Lancet 1998; 351: 145–46.Google Scholar
97Brace, V. Learning from adverse outcomes: developing a system for identification and assessment of severe maternal morbidity [MD thesis]. Birmingham University: 2006.Google Scholar
98Okong, P, Byamugisha, J, Mirembe, F, Byaruhanga, R, Bergstrom, S. Audit of severe maternal morbidity in Uganda – implications for quality of obstetric care. Acta Obstet Gynecol Scand 2006; 85: 797–804.Google Scholar
99Gandhi, MN, Welz, T, Ronsmans, C. Severe acute maternal morbidty in rural South Africa. Int J Gynaecol Obstet 2004; 87: 180–87.CrossRefGoogle Scholar
100Panday, M, Mantel, GD, Moodley, J. Audit of severe acute morbidity in hypertensive pregnancies in a developing country. J Obstet Gynaecol 2004; 24: 387–91.Google Scholar
101Woloshyowych, M, Neale, G, Vincent, C. Case record review of adverse events: a new approach. Qual Saf Health Care 2003; 12: 411–15.Google Scholar
102Wilson, R McL. Reviewing case record review. Qual Saf Health Care 2003; 12: 403–404.Google Scholar
103Kaul, V, Bagga, R, Jain, V, Gopalan, S. The impact of primary postpartum hemorrhage in “near-miss” morbidity and mortality in a tertiary care hospital in North India. Indian J Med Sci 2006; 60: 233–40.Google Scholar
104Geller, SE, Rosenberg, D, Cox, SM, Brown, ML, Simonson, L, Driscoll, CA et al. The continuum of maternal morbidity and mortality: factors associated with severity. Am J Obstet Gynecol 2004; 191: 939–44.Google Scholar
105Andersgaard, AB, Herbst, A, Johansen, M, Ivarsson, A, Ingemarsson, I, Langhoff-Roos, J et al. Eclampsia in Scandinavia: incidence, substandard care, and potentially preventable cases. Acta Obstet Gynecol Scand 2006; 85: 929–36.Google Scholar
106Bouvier-Colle, M-H, El Joud, DO, Varnoux, N, Goffinet, F, Alexander, S, Bayoumeu, F et al. Evaluation of the quality of care for severe obstetrical haemorrhage in three French regions. Br J Obstet Gynaecol 2001; 108: 898–903.Google ScholarPubMed
107Penney, G, Brace, V. ‘Near misses’ and severe maternal morbidity; the Scottish experience. In: Lewis, G (ed). Why Mothers Die 2000–2002. London: RCOG Press; 2004; p. 267–71.Google Scholar
108Penney, G, Kernaghan, D, Brace, V. Severe maternal morbidity: the Scottish experience 2003 to 2005. Why mothers die 2003 – 2005. RCOG Press; 2007. In press.Google Scholar
109Penney, G, Kernaghan, D, Adamson, L. Scottish Confidential Audit of Severe Maternal Morbidity. 3rd annual report 2005. Aberdeen: Scottish Programme for Clinical Effectiveness in Reproductive Health; 2006. p. 5–34.Google Scholar