Discussion
mistakes
POSTPARTUM HEMORRHAGE, ADVERSE EVENTS, DISEASE, TREATMENT ERROR, COMPLICATIONS, SHOULDER DYSTOCIA
This study tested the research hypothesis whether the frequency of preventable adverse events (pAEs) would decrease in the year following the implementation of a communication training addressing health care workers in obstetrics. Overall, 2,865 of all 3,351 births in the year 2018 were analyzed as reference year and 2,846 of all 3,302 births in the year 2020 after the training. A significant reduction in pAE was observed in terms of 13.35% in the year 2018 vs. 8.83% in 2020. Subjective ratings were in favor of the effectiveness of the intervention but as there was no active control groups or a randomized control trail, the effectiveness can only be concluded from this pre-experimental design. For the reduction in pAE, there are several background variations that could account for the reduction in pAE. Future research is needed to validate the findings accordingly.One should keep in mind that AEs in the treatment of patients will not be completely avoidable despite technical progress and sufficient training. Within the medical disciplines, obstetrics plays a special role. In the case of complications, fatal and possibly life-determining consequences can occur for mother and child, although the expectant mother is initially not a patient, and giving birth is a physical process and not a disease requiring treatment. However, the rise in maternal risk factors has increased the challenges for obstetric staff, who are additionally burdened by medico-legal aspects with a simultaneous increase in work pressure and reduced staff.AEs, responsible for morbidity and mortality in hospitalized patients, are reported to be between 3 and 17%, and up to 50% are considered preventable [However, in many studies, the data are evaluated retrospectively from different documentation systems, which in turn leads to difficult comparability and distortions. Often, the mostly complex and situational conditions in the documentation systems can neither be identified nor precisely assigned retrospectively.One method for standardized retrospective analysis of AEs is the "Harvard method" and the "Global Trigger Tool (GTT)". In a two-stage procedure, they retrospectively evaluated patient files for defined medical treatment errors. An additional 6-point scale was used to classify the preventability of the adverse events [Another tool for standardized recording and comparability of adverse events is the Adverse Outcome Index (AOI) [One paper that used this index to measure the effect of teamwork training failed to achieve the study objective of reducing the overall number of adverse events. Only the decision to deliver time in case of an emergency section was significantly reduced [The present study shows a statistically significant reduction in the total number of pAEs after a communication training was introduced. The communication training was substantially more focused on communication than on teamwork compared to other interventions. In most other interventions, teamwork training is implemented; but it requires sufficient preparation and resources at the site, such as time capacity or operating rooms [Another important aspect of the training was the role of hierarchies. Role-plays were used to practice giving timely warnings of possible avoidable mistakes in critical situations, regardless of the professional and hierarchical position of the person acting. The so-called "Speaking-Up" should help to overcome hierarchical levels to address safety-relevant concerns and thus increase patient safety [In general, staff reported that the training increased their awareness of safe and effective communication. The general awareness of the role of communication was strengthened in the training using an educational film [An extensive review of the effectiveness of communication training in obstetrics examined 71 studies, which showed large differences in the quality and design of communication training and studies [To reduce pAEs through training, it is particularly important to understand their key active components making the training work. As early as the 1990s, a key role was attributed to the human factors. Even though AEs caused by human factors will never be 100% preventable, effective risk management should always include communication training to strengthen the human factors in the team [In the future, in addition to strengthening human factors, it may also be useful to include addressing risk factors in a structured risk management. In the present work, risk factors were filtered in the cases of an AE. If risk factors are differentiated into those that can be controlled and those that cannot be or controlled, this can be included in individualized risk management. In this way, risk factors that can be controlled can be clearly communicated to the team and appropriate prophylactic measures can be taken. Checklists, adapted for the most important obstetric risk factors, are useful tools for risk-conscious individual birth management [Limitations must be considered when interpreting the present results. In the evaluation of the individual categories of pAEs, no statistically significant reductions were found in peripartum therapy delay. This can be explained, among other reasons, by an insufficient differentiation of the categories so that our data cannot reflect pAE according to whether they occurred before, during or after birth. In the future, it may be useful to differentiate these categories into antepartum, peripartum, and postpartum birth management. In addition, management of special obstetric emergencies such as emergency cesarean section, shoulder dystocia, or postpartum hemorrhage should be considered. There was no statistically significant improvement in inadequate fetal monitoring, indicating that not all pAE improved over the course of the analysis. However, this does not impact the study findings negatively because effects of improvement in this category are more likely to come from special training that teaches the interpretation of CTGs during labor than from general communication training [The main limitation is the lack of a control group. A pre-post comparison of the period after the training without the possibility of controlling the results for the communication training was conducted. Therefore, it cannot be ruled out that the reduction in pAEs is at least partly due to the further development in obstetric care or to other influences for which no controls could be conducted. It is possible that a heightened awareness had an unsystematic impact on pAE instead of systematic training effects. Moreover, the background variations must be considered, as the sample size comprises a large number of cases and this complicates the specific evaluation of the reduction in pAEs. In addition, the impact of the COVID-19 pandemic must be considered. Theoretically, the training helped to mitigate the negative effects of the pandemic, but we also do not have a comparator with this regard to test for the mechanisms. Accordingly, we cannot link the reduction of pAE to the intervention without alternative explanations and future research is needed to establish whether communication trainings can actively reduce pAE.In addition, only half of the training participants completed the questionnaires in a form that could be evaluated. Thus, the evaluation results must be interpreted with caution due to the potentially selective drop-out and lower power. It is possible that mostly HCW who experienced the intervention as helpful answered the questionnaire at the second time point while the more critical ones did not. The hospital where the intervention and analyses were conducted is a teaching hospital with a corresponding high staff turnover. In the period between the measurements before and after the intervention, people may have left the obstetrics department and accordingly were no longer available to respond. In collecting the data, the present study used retrospective routine data that can be extracted and analyzed at any time point. In addition, the conditions for pAEs, especially the communication aspect, cannot always be retrieved from the available documentation systems with perfect validity and reliability. This reduces the quality and consequently the internal validity of the extracted routine data. Thus, this opens many further questions, which should be researched in the future.