Implantación de un sistema de gestión de riesgos en obstetricia: aprendiendo de los errores

Abstract

Objective To describe the implementation of a patient safety program in an obstetrics department and the results obtained. Material and methods The program was applied in all women admitted to the labor and delivery unit. To detect adverse events, a patient safety indicator system that allows monitoring over time was designed and an anonymous event reporting tool was activated. Results An adverse event occurred in 9.26% of hospitalized patients. Adverse events were more common in the puerperium (6.61%) and after cesarean delivery (16.04%) than in instrumental (10.63%) and vaginal delivery (7.40%). Most of the notifications concerned potential adverse events (near misses) and 72% led to improvements. Conclusions Our program detects adverse events and allows improvement measures to be designed. In obstetrics, safety is of great importance because of the potential effects to mother and child. Furthermore, childbirth is a frequent cause of hospitalization and litigation in obstetrics is common.