Systematic approaches to adverse events in obstetrics, Part II: Event analysis and response

Abstract

The critical arm of improvement and change comes after events are identified and classified. Getting and making things right when things go wrong defines a successful safety program. This article reviews the important tasks that should be familiar to any team approaching a serious event on an obstetrics unit. Root cause analysis is a critical, but often misunderstood, tool for dissecting the contributing factors leading to an adverse event. Successful root cause analyses have a standardized approach that result in meaningful action plans. Disclosure to the patient of the event and error, if applicable, is a new concept that is gaining traction in medicine. The review of a structured disclosure program can help programs adopt a method that has successfully gained the trust of patients and families with very few complications. Second victim support through coordinated debriefing of the individuals and teams who worked during the event is a final important measure that is important to prevent burnout or identification and classification is just the beginning to having a systematic approach to adverse events. The critical arm to improvement and change comes in the analysis and response to these events, which includes root cause analysis, corrective action plans, error disclosure, and second victim support.