Evaluation of adverse and preventable adverse events
death, confusion
POSTPARTUM HEMORRHAGE
In the first phase of the project, pAEs were defined with the help of a list of criteria based on international research results as well as in project meetings with participants from different professions [Based on the defined list of criteria, data were extracted from the obstetric documentation system of the University Hospital Ulm, Department of Gynecology and Obstetrics, Perinatal Center Level 1 , by clinical documentation assistants. All available data sources were used, such as the hospital's birth documentation (i.s.h.med system), the obstetric viewpoint system, and handwritten birth documentation. Pregnancies with less than 36 weeks gestation were excluded; multiple births were counted as one case.Of a total of 3,351 births in the calendar year 2018 (reference year), 2,865 case records met the inclusion criteria, which were retrospectively evaluated for AEs according to the criteria of the previously defined list. The determination of preventability was independently assessed by an interprofessional team of three physicians and midwives based on the complete case analysis. Outcomes were classified into six defined categories for pAEs according to potential patterns of causation: 1) peripartum treatment delay (e.g., delayed intervention at birth, delayed intervention for postpartum hemorrhage), 2) diagnostic error (e.g., misdiagnosis of fetal birth position), 3) inadequate birth position, 4) organizational errors (e.g., lack of training, lack of documentation of birth progress), 5) inadequate fetal monitoring (e.g., fetal heart rate/maternal heart rate confusion on cardiotocography (CTG) or misinterpretation of the CTG, near-sudden infant death), and 6) medication errors. Each case could also be assigned to more than one category. In addition, the pAEs were evaluated according to obstetrically relevant risk factors and 13 risk factors, which include controllable and uncontrollable factors, were extracted [For the present study, using the same criteria, the pAEs and risk factors in the obstetric data records of the calendar year 2020 after communication training in the same clinic were evaluated. From a total of 3,302 births, 2,846 case records were extracted analogously to the exclusion criteria mentioned above. To determine the communication training effect, the identified pAEs of 2018 and 2020 were compared according to categories and risk factors.