Patient-related adverse events in the maternity units at Tokollo/Mafube district Hospital complex
Date
2011-10-27
Authors
Noge, Sesi Roslina
Journal Title
Journal ISSN
Volume Title
Publisher
Abstract
BACKGROUND: The Tokollo/Mafube District (TMD) Hospital Complex located in the
rural area of Fezile Dabi District within the Free State Province has reported a high
number of adverse events (AE) from the maternity units. Although the information linked
to AE occurring in the hospitals is routinely collected and reported to the hospital
management in accordance with the Provincial policy, no study has been done to
systematically analyse the available information and to explore the current situation.
AIM: To describe the patient-related AE in the maternity units of TMD Hospital Complex,
related individual and health system factors, and the functioning of the reporting system
used for these AE during the two year study period.
METHODOLOGY: A descriptive cross-sectional study design was used, based on a
retrospective review of routinely collected hospital data from the health records of
patients, the AE Committee meeting minutes, and other relevant hospital documents.
The study was conducted at the maternity units of TMD Hospital Complex which
consists of two hospitals in the Fezile Dabi District within the Free State Province. Data
was collected in the following categories of variables: the types of AE (in terms of levels
of seriousness), the profiles of patients who experienced such AE (e.g. age, gravidity,
marital status, residence, and socio-economic status), the related health system factors
identified during the adverse events committees meetings (such as personnel, transport,
equipment, environment and management) and reporting of these AE.
RESULTS: This study revealed that a total of 88 patients, comprising 0.8% of the total
number of admissions to the maternity units, experienced AE. Maternal AE occurred
more commonly than perinatal AE. The majority of women experiencing AE were
unemployed (93%), between the ages of 19-34 (81%), unmarried (79%) and resided in
towns (88.6%). In addition, most of these women belonged to the groups of primigravida
and multigravida (85%), attended between one and three antenatal visits (42%), and delivered via normal vaginal deliveries (76%) with a high number of stillborns (77.2%).
Overall, the majority of maternal AE occurred during the intrapartum stage. Another
significant finding was that majority of AE reported were classified as the most serious
being SAC 1, which accounted for 93% of the maternal AE and 84% of perinatal AE.
The early perinatal AE accounted for 100% of the reported perinatal AE.
Although majority of AE reported at the institution were within the prescribed period,
reporting time to the Complex AE Committee (CAEC) and District AE Committee
(DAEC) was exceeded in the majority of cases. In addition, all AE that required
investigation complied with the provincial policy but exceeded the required investigation
period.
The findings regarding health systems related factors as determined by root cause
analysis performed by the AE committee revealed that clinical governance issues
accounted for 43% of both maternal and perinatal AE, followed by patient transport
issues as provided by the Emergency Medical Services (EMS) which also accounted for
a significant percentage (33%).
CONCLUSION: This study has demonstrated that specific health system related factors
played a significant role on the occurrence of AE at the maternity units of TMD Hospital
Complex and that the majority of the reported AE were very serious (SAC 1). It is
important that these preventable, contributory factors are addressed by management at
both the complex and district levels. Furthermore the results suggest that patients’
profiles, to a certain extent, do have an influence on the occurrence of AE in maternity
units of TMD hospital Complex and it is important that patients’ profiles be taken into
consideration when adverse incidents are analysed.