Near miss audit in obstetrics

Current Opinion in Obstetrics and Gynecology

Volumn 19, Issue 2, 2007, Pages 145-150

  Penney, Gillian ^a,b   Brace, Victoria ^b  

^a UNIVERSITY OF ABERDEEN   (United Kingdom)

^b ABERDEEN MATERNITY HOSPITAL   (United Kingdom)

Author keywords

Adverse event; Clinical audit; Maternal morbidity; Maternal mortality; Near miss

Indexed keywords

HEALTH CARE QUALITY; HUMAN; HYSTERECTOMY; INCIDENCE; INTENSIVE CARE UNIT; INTERVIEW; MEDICAL RECORD; MORBIDITY; MORTALITY; OBSTETRICS; PERINATAL CARE; POSTPARTUM HEMORRHAGE; PRIORITY JOURNAL; REVIEW; SURVIVAL; TIME SERIES ANALYSIS;

DEVELOPED COUNTRIES; FEMALE; HUMANS; MATERNAL MORTALITY; MEDICAL AUDIT; MORBIDITY; OBSTETRIC LABOR COMPLICATIONS; OBSTETRICS AND GYNECOLOGY DEPARTMENT, HOSPITAL; PREGNANCY; PUERPERAL DISORDERS;

EID: 33947149189     PISSN: 1040872X     EISSN: None     Source Type: Journal    
DOI: 10.1097/GCO.0b013e328014a860     Document Type: Review

References (31)

1. Confidential enquiry into maternal and child health. Why mothers die: 2000-2002. Sixth report on confidential enquiries into maternal deaths in the United Kingdom. London: Royal College of Obstetricians and Gynaecologists; 2004. pp. 1-338.
2. Beyond the numbers: reviewing maternal deaths and complications to make pregnancy safer. Geneva: WHO Press; 2004.
3. Geller SE, Cox SM, Callaghan WM, Berg CJ. Morbidity and mortality in pregnancy: laying the groundwork for safe motherhood. Women's Health Issues 2006; 16:176-188.
4. Pattinson RC, Say L, Makin JD, Bastos MH. Critical incident audit and feedback to improve perinatal and maternal mortality and morbidity. Cochrane Database Syst Rev 2006; (4):CD002961. •• A rigorous systematic review from the Cochrane Collaboration which shows that no randomized controlled trials have been conducted to confirm the effectiveness of critical incident audit in improving maternal or perinatal outcomes.
5. Lu MC, Fridman M, Korst LM, et al. Variations in the incidence of postpartum hemorrhage across hospitals in California. Matern Child Health J 2005; 9:297-306. • This paper usefully summarizes the strengths and limitations of using routinely collected administrative data for adverse event audit.
6. Cameron CA, Roberts CL, Olive EC, et al. Trends in postpartum haemorrhage. Aus N Z J Public Health 2006; 30:151-156.
7. Sheikh L, Zuberi NF, Riaz R, Rizvi JH. Massive primary postpartum haemorrhage: setting up standards of care. J Pak Med Assoc 2006; 56:26-31. • A good example of a hospital-based adverse event audit which prompted local action in the form of development of clinical protocols.
8. Kaul 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; 60:233-240. • A further example of hospital-based adverse event audit which illustrates its feasibility in a developing country setting.
9. Eniola OA, Bewley S, Waterstone M, et al. Obstetric hysterectomy in a population of south east England. J Obstet Gynaecol 2006; 26:104-109. • A population-based study of the incidence of peripartum hysterectomy. Rigorous methods, employing multiple sources, were used for case ascertainment. It provides a robust estimate of incidence which other groups may use for comparison.
10. Simoes E, Kunz S, Bosing-Schwenkglenks M, Schmahl FW. Association between method of delivery, puerperal complication rate and postpartum hysterectomy. Arch Gynecol Obstet 2005; 272:43-47.
11. Kwee A, Bots ML, Visser GH, Bruinse HW. Emergency peripartum hysterectomy: a prospective study in the Netherlands. Eur J Gynaecol Oncol 2006; 124:187-192. • A further study of incidence of peripartum hysterectomy from multiple hospital sites.
12. Selo-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 Gynecol Obstet 2005; 272:207-210. •• A hospital-based study of obstetric admission to an intensive care unit. A case-control design permits the quantification of risk factors for admission.
13. Keizer JL, Zwart JJ, Meerman RH, et al. Obstetric intensive care admissions: a 12-year review in a tertiary care centre. Eur J Obstet Gynecol Reprod Biol 2006; 128:152-156. • A further hospital-based study of obstetric admission to an intensive care unit.
14. Zeeman GG. Obstetric critical care: a blueprint for improved outcomes. Crit Care Med 2006; 34:208-214.
15. Knight M, Kurinczuk J, Brocklehurst P. UK obstetric surveillance system uncovered. RCM Midwives 2005; 8:38-39. •• A useful overview of the important UK-wide obstetric surveillance scheme administered by the National Perinatal Epidemiology Unit based in Oxford.
16. Baskett TF, O'Connell CM. Severe obstetric maternal morbidity: a 15-year population-based study. J Obstet Gynaecol 2005; 25:7-9. • A regional audit of multiple categories of near miss morbidity based on routinely collected data. A good example of the usefulness of this approach sustained over many years.
17. Wen SW, Ling H, Liston R, et al. Severe maternal morbidity in Canada, 1991-2001. CMAJ 2005; 173:1-6. •• A Canada-wide near miss audit based on routinely collected data. Illustrates the potential for conducting sustained near miss audit even if limited to routinely collected data.
18. Zhang W-H, Alexander S, Bouvier-Colle MH, Macfarlane A, the MOMS-B Group. Incidence of severe preeclampsia, 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. •• A good example of an international collaboration which employed rigorously developed definitions of near miss. It highlights the feasibility of generating international comparisons and the challenges of ensuring that definitions are applied in a similar way in different settings.
19. Minkauskiene M, Nadisauskiene RJ, Padaiga Z. Severe and acute maternal morbidity: Lithuanian experience and review. Int J Fertil Womens Med 2006; 51:39-46. • A good example illustrating the feasibility of multicentre, multiple category near miss audit in a resource-poor setting.
20. Filippi V, Ronsman C, Gohou V, et al. Maternity wards or emergency obstetric rooms? Incidence of near-miss events in African hospitals. Acta Obstet Gynecol Scand 2006; 84:11-16. • A further example of the feasibility of multicentre, multiple category near miss audit in resource-poor settings.
21. Dumont A, Gaye A, Mahe P, Bouvier-Colle MH. Emergency obstetric care in developing countries: impact of guidelines implementation in a community hospital in Senegal. BJOG 2005; 112:1264-1269. • A hospital-based study illustrating the usefulness of a short-term near miss audit to demonstrate the impact of local introduction of clinical guidelines.
22. Rosenberg D, Geller SE, Studee L, Cox SM. Disparities in mortality among high risk pregnant women in Illinois: a population based study. Ann Epidemiol 2006; 16:26-32. • Provides a useful overview of the US mechanism for routine surveillance of maternal mortality. Also shows the commitment of the CDC to extend their studies to encompass morbidity.
23. Geller SE, Cox SM, Kilpatrick SJ. A descriptive model of preventability in maternal morbidity and mortality. J Perinatol 2006; 26:79-84.
24. Weeks AD, Alia G, Otolorin EO, Mirembe FM. A criteria-based audit of the management of severe preeclampsia in Kampala, Uganda. Int J Gynaecol Obstet 2005; 91:292-297.
25. Weeks A, Lavender T, Nazziwa E, Mirembe F. Personal accounts of 'near-miss' maternal mortalities in Kampala, Uganda. BJOG 2005; 112:1302-1307. • A useful example of the use of interviews with survivors of near miss morbidity as one approach to assessment of quality of care.
26. Singh J, O'Donovan M, Coulter-Smith SD, Geary M. An audit of the use of magnesium sulphate in severe preeclampsia and eclampsia. J Obstet Gynaecol 2005; 25:15-17.
27. White AA, Pichert JW, Bledsoe SH, et al. Cause and effect analysis of closed claims in obstetrics and gynecology. Obstet Gynecol 2005; 105:1031-1038. • A useful example of the use of 'closed claims' (cases in which the possibility of litigation had been identified) as a source of cases for near miss review.
28. Angelini DJ, Greenwald L. Closed claims analysis of 65 medical malpractice cases involving nurse-midwives. J Midwifery Women's Health 2005; 50:454-460.
29. Fowler SJ. Provision for major obstetric haemorrhage: an Australian and New Zealand survey and review. Anaesth Intensive Care 2005; 33:784-793.
30. Beathe Andersgaard A, Herbst A, Johansen M, et al. Eclampsia in Scandinavia: incidence, substandard care, and potentially preventable cases. Acta Obstet Gynecol Scand 2006; 85:929-936. • A useful example of a population-based audit of a single category of near miss event which incorporated systematic assessment of quality of care and preventability.
31. Penney G, Adamson L, Kernaghan D. Scottish confidential audit of severe maternal morbidity: 2nd annual report 2004. Aberdeen: Scottish Programme for Clinical Effectiveness in Reproductive Health; 2005. pp. 1-32. • A population-based audit of multiple categories of near miss which includes estimation of rates and systematic assessment of quality of care and preventability.