Miss Events Research Articles

A review of maternal near miss events in a tertiary teaching hospital- A tool for improving quality of obstetric care in developing countries: A descriptive study

: In 2015, the United Nations Member States adopted the Sustainable Development Goals (SDGs), which include reducing the maternal mortality (MM) ratio by two-thirds by 2030. Maternal mortality rates are alarming, especially in low-income countries where 99% of all maternal deaths occurs. Maternal Near Miss event was described by the World Health Organization (WHO) as “A woman who is close to death survived a complication that occurred during pregnancy, delivery or up to 42 days of termination of pregnancy.” This concept was launched in the health system. Maternal near-miss audit was recognized as a useful tool to improve the quality of obstetric care. A descriptive study was conducted at PCMC’s Postgraduate Institute and YCM Hospital Pimpri Pune (Maharashtra) from 1st January 2020 to 30 June 2021. During the study period, Maternal Near miss (MNM) cases were identified as per WHO criteria for enrolment. This study reviewed near-miss cases with aim to study baseline assessment, to analyse cause and intervention to improve health cases.: Of total 9534 admissions, 130 mothers had severe maternal outcomes (114 maternal near-miss cases and 16 maternal deaths). 104(91.23%) MNM cases were between the ages of 20-35 years, 72.13% were from rural, 78(68.42%) were referred from health facilities.Seventy two(63.86%) were multigravida. Sixty Nine (60.53%) had hypertension in pregnancy followed by 62 (54.39%) had haemorrhage.: Our study concluded hypertension in pregnancy and haemorrhage are major causes of MNM cases. ICUs and blood banks play a pivotal role in the prevention of maternal mortality. Developing countries should aim to improve maternal health outcome by improving HDU/ICU facilities and blood bank to reduce maternal mortality.

Obstetric Near Miss Events at a Tertiary Care Centre, Birgunj

Introduction: Near miss cases are the ones who nearly died but survived a complication that occurred during pregnancy, childbirth, or within 42 days of termination of pregnancy. Near-miss is recognized as the predictor of the level of care and maternal deathand thereforea review of near-miss obstetric eventsis useful to investigate maternal mortality. The study was meant to determine the ratio and nature of near-miss obstetric cases and associated factors.Materials and Methods: This was a prospective observational study done in the Department of Obstetrics and Gynaecology at National Medical College and Teaching Hospital from 1st February 2022 to 31st January 2023. Ethical approval was obtained from IRC (Ref. F-NMC/537/077-078).The near-miss cases were identified among the admitted obstetric cases using the five-factor scoring system and followed till their discharge or death.The assessment of the causes of near-miss cases was done.Results: During the study period, 1163 live births, 33 near-miss cases, and5 maternal mortalities were recorded. The incidence of near-miss was 28.37 per 1000 live births, the mortality index was 13.16% and the near-miss to maternal mortality ratio was 6.6: 1. Haemorrhage (39.39%) was the most common event responsible for near-miss, followed by hypertensive disorders (24.24%). Similarly, cardiovascular (78.79%) was the most common organ dysfunction recorded, followed by hepatic (33.33%).Conclusion: Haemorrhage and hypertensive disorders are the major causes of near-miss events. Identification and evaluation of the factors of near-miss cases can reduce maternal morbidity and mortality, as special preventive actions for the management of its complications can be planned. It is also worth presenting near-miss cases in national indices.

Prevalence and Risk Factors Associated with Maternal Near Miss Events in the Upper East Region of Ghana

A maternal near miss (MNM) event is a severe life-threatening maternal morbidity that reflects quality of obstetric care. It is considered a proxy of maternal mortality and predictor of quality obstetric care. The major underlying causes of MNM are hypertensive disorders, obstetric hemorrhage, sepsis and abortion complications. MNM is a more frequent event than maternal mortality and share several features together. Inquiries intodeficiencies andcritical assessment of health care quality, identify health system deficiencies, and help develop robust strategies for maternal care. We conducted a cross-sectional descriptive study to determine the prevalence and underlying causes of MNM. The study respondents were women aged 15 - 49 years with pregnancy experience in 2020 who had health facility care. Primary and secondary data were collected at households and health facilities respectively using electronic platform, KoBoCollect. STATA version 15.0 was used to analyze the data. The prevalence of MNM was 11.30%. The main underlying causes were complications of caesarean section, hypertensive disorders, anemia, obstructed labor, and antepartum hemorrhage. The main signal functions of emergency obstetric and newborn care (EmONC) employed to avert death were parenteral antibiotics, blood transfusion, caesarean section, and magnesium sulphate. The prevalence of MNM in the Upper East region was high. The region can reduce severe maternal morbidity and mortality by strengthening health systems, improving access to high-quality obstetric care and training healthcare providers to prevent and treat the major underlying causes of MNM identified in this study. Keywords: Ghana, MNM, Mortality, Prevalence, Antepartum, Hemorrhage, EmONC.

In-Hospital Newborn Falls and Near Miss Events: A Need to Report.

This study aimed to evaluate the clinical characteristics of the neonates who fell in the maternity ward and identify the incidence of near miss events during the immediate postpartum period. The study consisted of two steps. The retrospective part included the evaluation of admissions due to the in-hospital newborn fall for 6 years. The prospective part included the assessment of the near miss events (any probability of falling of the newborn; either cosleeping or an incident with a possible consequence of falling of the newborn) in the postpartum clinic (<72 hours after delivery) for a period of 4 weeks. The details of the events and clinical outcomes were recorded. A questionnaire about fatigue was administered to mothers who experienced near miss event. Seventeen in-hospital newborn falls were recorded: 1.8 to 2.4/10,000 live births. The median age of the neonates when the fall occurred was 22 (16-34) postnatal hours. Fourteen events (82%) occurred between 10 p.m. and 6 a.m. All neonates who experienced a fall were discharged without any known adverse outcomes. Twelve mothers (71%) had experienced a near miss event before. In the prospective arm of the study, 67 out of 804 mothers (8.3%) were found to experience a near miss event (44/1,000 days of postpartum hospitalization). Thirty-two events (49%) occurred in the first postpartum day. Fifty-two events (78%) occurred between 10 p.m. and 6 a.m. Fifty-eight mothers (86%) had no companion. Sixty-three percent of the mothers expressed intense fatigue after delivery. In-hospital newborn fall may occur in the postpartum period, and near miss events should warn clinicians for a probable fall event. The nighttime shift requires more attention regarding the prevention of both the fall and the near miss events. Immediate postpartum mothers are needed to be observed carefully. · In-hospital newborn falls occurred mainly during the night shift.. · Nearly two-third of the mothers whose newborn was fallen experienced a previous near miss event.. · Any near miss event in the hospital was detected in 8.3% of mothers..

Evaluation of Maternal Near Miss Events at Tibebe Ghion Specialized Hospital in Bahir Dar, Ethiopia

Objective To estimate: 1) the prevalence of maternal mortality and severe morbidity (Maternal Near Miss (MNM)); and 2) associated risk factors, at a tertiary referral hospital in Bahir Dar, Ethiopia. Methods Prospective data collection of 658 consecutive delivering pregnant patients and their neonates at Tibebe Ghion Specialized Hospital (TGSH) in Bahir Dar, Ethiopia, from February 26-June 10, 2020. Demographic and outcome data were collected as part of a quality improvement initiative using the REDCap mobile app. Univariable and multivariable logistic regression were used to investigate the relationship between the key demographic and clinical variables with MNM. Results There were no maternal deaths and 70 MNM during the study period. The median patient age was 26 years (IQR 23-30); 49% of women were nulliparous, and 56% delivered vaginally. Patients had higher odds of experiencing MNM if living in a rural area (OR=3.71, p&lt;0.01) or with a hypertensive disorder of pregnancy (OR=2.27, p=0.03). The postpartum hemorrhage rate was 1.7%. Conclusion The MNM and mortality rates at TGSH were less than elsewhere in the region. Living in a rural area and having hypertensive disorders of pregnancy were major predictors of MNM events. Multiple areas were identified where quality improvement projects could be developed.

Study of Maternal Near Miss Events at Nepal Medical College and Teaching Hospital

Maternal near miss (MNM) is defined as woman who nearly died from complication during pregnancy, childbirth or within 42 days of termination of pregnancy but survives either due to care she receives or due to chance. Maternal near miss and maternal deaths share many characteristics and pathological processes and MNM being more frequent than death, review of MNM gives us an opportunity to assess the quality of obstetric care in the institutions and area of improvement. As maternal morbidity precedes maternal deaths, the study of near miss cases provides understanding of the determinants of maternal morbidity and mortality and help in reducing it. The aim of this study was to assess the MNM events in our institutions based on WHO organ dysfunction-based criteria. A descriptive cross-sectional study was carried out in a tertiary care hospital in Kathmandu over two years period from July 2020 to June 2022 after taking ethical clearance from Institutional Review Committee. During the study period, there were 3493 live births, 40 maternal near miss cases and no maternal deaths. The MNM ratio was 11.45/1000 live births and the prevalence of MNM was 1.13%. Postpartum hemorrhage 11 (27.5%), early pregnancy complications 8 (20%) and hypertensive disorder of pregnancy 5 (12.5%) were the major contributor of MNM. Coagulation/ Hematological system dysfunction 22 (55%) was the most common organ involved in MNM. ICU admission and blood transfusion more than five units were the common intervention done. Effective use of critical care, evidence-based intervention and timely referral will help to reduce maternal morbidity and mortality.

123 Supporting A Learning System in Paediatric Emergency Pathways; Using Organisational Comparisons, Serious Incidents and Near Miss Events To Improve The Diagnosis And Treatment Of Testicular Torsion

Abstract Introduction Scrotal pain is a common presentation to the emergency department requiring prompt investigation and management to identify testicular torsion. Using national data we aim to identify key suboptimal areas in the acute diagnosis and management of testicular torsion with a view to improving outcomes. Method A freedom of information request was made to all Trusts in England that manage testicular torsion. Serious Incidents (SI's) were analysed to see if those with Paediatric Emergency Departments fared better than those without. In addition, a qualitative thematic analysis of the NHS England Strategic Executive Information System database from 2007-2019 was undertaken, identifying common themes associated with orchidectomies and ‘near miss’ events in children. Results 304 serious incidents were returned with 62 Orchidectomies and 242 Near Miss Events. Misdiagnosis of symptomatic testicle was not significant when comparing ED to specialists (OR = 1.46, p = 0.3842). Atypical presentation resulting in orchidectomy was significant when comparing ED to specialists (OR = 6, p = 0.0355). Near miss events are due to a variety of factors. There was no statistical significance in incidents when comparing ED's caring for all ages with Paediatric EDs U = 807.5, z = -1.124, p = 0.261. Conclusions There's a need for education in ED about atypical presentation of testicular torsion and examination of scrotum in cases of lower abdominal pain. It's also vital that specialist teams are cognisant of the standard operating procedures relevant to scrotal pain. Finally, there should be a drive for annual audit in Urology and ED units with regards to testicular torsion as SI's may be under-reported.

Analysis of Maternal Factors Impacting Neonatal Near Miss (NNM) Events: A Tertiary Centre Experience.

To find out the incidence of neonatal near miss (NNM) cases in comparison with the neonatal deaths and to study the different antenatal and intrapartum maternal variables and system-related delays influencing these events. This is a descriptive retrospective study conducted over a year (2018-2019) at a tertiary referral hospital in India, where NNM cases were selected as per 'pragmatic criteria', and detailed maternal and neonatal biological variables and near miss indicators were procured from the medical record books and analysed. Out of 6383 live births and 231 neonatal deaths in the hospital during the study period, 810 NNM cases were identified born to 710 mothers, i.e. 3.5 cases for each neonatal death. Birth weight and gestational age in combination contributed to the maximum number of cases-383 (47.28%). The most common reason for referral was threatened pre-term/PPROM with non-availability of NICU-197 cases (38.3%) out of 514 referrals. Out of 710 mothers, 529 (74.5%) had at least one comorbidity at the time of presentation. The most common comorbidity was anaemia in 267 women followed by hypertensive disorder of pregnancy-in 251 cases. Primary delay contributed to 54% of all delays in the study. NNM can be used as an effective tool for quality control and audits to effectively reduce maternal and neonatal morbidity and mortality but needs more research to establish a standardized definition and criteria for selection of cases.

Maternal Near Miss Analysis in Three Hospitals of Nepal: An Assessment Using Three Delays Model.

Maternal Near Miss cases have similarities with those dying from such complications and so present an important opportunity to improve practice. This study was conducted to assess the prevalence of Maternal Near Miss events and identify the delays experienced. This was a facility-based cross-sectional study conducted in three tertiary referral hospitals from three provinces of Nepal. All the women surviving a near miss event during six months data collection period were included in the study. There were 67 near miss cases, 7 maternal deaths, and 9158 live births in the study hospitals during the data collection period. This resulted in Maternal Near Miss ratio of 7.31/1000 live births and facility-based Maternal Mortality Ratio of 76/100,000 live births. Severe obstetric haemorrhage (54%) was the most frequent clinical cause of near miss, followed by hypertensive disorders (43%). At least one type of delay was experienced by 85% women. First delay occurred in 63% (42 of 67) cases, second delay occurred in 52% (33 of 62) cases and third delay occurred in 55% (37 of 67) cases. This study found out that all three delays were common among women experiencing maternal near miss event. Raising awareness regarding dangers signs, improving referral system and strengthening ability of health workers can help in reducing these delays.

Maternal Near Miss Events in Tertiary Care Hospital: A Retrospective Observational Study

Introduction: Over the years, continuous efforts have been made for improving reproductive health status of women. In India, Ministry of Health and Family Welfare (MoHFW) has set Maternal Near Miss (MNM) review operational guidelines. Aim: Analysis of the incidence and causes of MNM cases in tertiary care hospital. Materials and Methods: This retrospective observational study was undertaken at a tertiary care hospital from January 2010 to September 2018. MNM cases were identified according to the criteria given by MoHFW, MNM review operational guidelines. Following parameters (variables) were noted viz., age, parity, obstetric haemorrhage, severe anaemia, sepsis, therapeutic interventions, etc., and analysed. Quantitative data was analysed by calculating means, ratios and proportions, using SPSS software (Version 21.0). Results: There were total 36,366 deliveries during the study period. A total of 315 Maternal Near Miss cases were noted. Hypertensive disorders n=133 (42.2%) in pregnancy was the leading cause of MNM events at the hospital. This was followed by obstetric haemorrhage n =97 (30.79 %), and severe anaemia constituting n=36 (11.42%), and Sepsis n=30 (9.52%). Mortality index was highest in the sepsis group n=5 (14.28%) followed by severe anaemia n=3 (7.69%). Conclusion: Hypertensive disorders were most common cause of near miss cases followed by obstetric haemorrhage. Sepsis was commonest cause of maternal mortality. Early identification of hypertensive disorders in pregnancy, obstetric haemorrhage, severe anaemia and sepsis; and prompt treatment of these causes may help in reducing near miss and maternal mortality.

A Canadian consensus definition of near-miss events in liver surgery for the real-time quality benchmarking of laparoscopic liver surgery

Presenter: Samuel Wilson | University of Ottawa Background: Conventional measures of the safety of a novel surgical technique rely on generic indicators of morbidity. However, adverse events, especially serious adverse events, may be rare and small studies may be underpowered to detect them. Specific patterns of complications with novel technologies may only become apparent once the technology has already been widely implemented. Near Miss Events (NMEs) may be more common than serious adverse events, and we hypothesize that they can be used for the real-time quality benchmarking of disruptive surgical technologies. The objective of this study is to define and classify NME in open and laparoscopic liver surgery. Methods: A modified Delphi methodology was used to assess surgical-expert opinions on important NMEs. A local panel at a Canadian tertiary care centre developed the initial survey and distributed it to a working group on NME in liver surgery formed through the membership of the Canadian Hepato-Pancreatico-Biliary Association. Responses were reviewed and condensed into categories that were redistributed to the survey participants for final ranking. Results: Twenty-two experts participated in the first iteration and 18 experts participated in the second iteration of the modified Delphi methodology. The top four NME categories identified were: 1) vascular NME 2) laterality and spatial orientation NME 3) oncological NME, and 4) adjacent organ injury NME. In total, consensus was reached on thirteen NME within these categories after the second iteration of the modified Delphi process. A validation step with clinical vignette assessment is currently ongoing. Conclusion: NME in liver surgery have been defined by a consensus of Canadian expert surgeons for use in real-time quality benchmarking of novel surgical techniques.

Radiation Oncology Learning Environment and Near Miss Events

Near misses, defined by harm averted due to chance or intervention, are low-cost learning opportunities in radiation oncology. We examine effects of near miss type and learning environment characteristics, such as psychological safety (PS) and time for reflection (TF), on incident reporting and recognition as success versus failure. We posit that perceiving the incident as success is correlated with perceptions of departmental willingness to report (WTR), and that these ratings would differ by near miss type. We also assess the relationship of psychological safety (PS) and time for reflection (TR) with departmental WTR. We administered a survey to members of a radiation oncology department with an incident learning system (ILS). The survey presented six incidents (4 near misses, 1 control, 1 hit) for a patient receiving intravenous contrast: process-based catch with harm averted by systematic creatinine check; good catch with harm averted by staff incidentally checking creatinine; could-have happened harm averted by chance normal creatinine; almost-happened harm with patient’s creatinine elevated and no sequelae; hit event with kidney injury; and control event with normal, checked creatinine and no sequelae. Subjects rated each event for success and departmental WTR on a 1-7 Likert scale, and answered validated PS and TF instruments. ANOVA and ordered logistic regression were used to assess WTR and success rating differences among near miss types, correlations with PS and TR, and real incidents coded as near miss in the department’s ILS database between 2014-2018. The survey yielded 97 of 127 responses (76.4%). Within each near miss type, success rating and WTR were negatively correlated (p<0.0001). There was no difference in WTR nor success ratings among near miss types (p=0.87). Male subjects exhibited a greater trend towards WTR hit events compared to female subjects (p=0.058). TR showed a positive trend with almost-happened events (p=0.085) and was significantly correlated with departmental WTR hits (p=0.007). However, TR showed a negative trend in real ILS reporting of near miss incidents (p=0.077). PS for attending physicians was significantly greater than that for therapists (5.68 vs. 3.56, p = 0.001). TF for therapists (4.31, p=0.034), physicists/dosimetrists (4.18, p=0.007), and nurses/medical assistants (4.33, p=0.048) were significantly less compared to that of physicians (5.81). In free text responses, subjects described the ILS as a platform to report “problems.” Near misses perceived as failures (vs. successes) are more likely to be reported, which corroborates the perception of the ILS as a platform to share problems. Greater time for reflection is correlated with the perception of others’ willingness to report harmful events, though less reflection time may be associated with personal ILS submissions, perhaps due to hierarchical role differences.

Obstetric Near Miss Events in a Tertiary Research Level Teaching Hospital

Background: Objective of the study was to identify the important causes of near miss cases and to evaluate the key interventions for the management and ultimate maternal outcome.Material and methods: In this case series study, critically ill pregnant, laboring or postpartum women who were admitted either directly or through referral to the National Medical College, Birgunj, Nepal, formed the study group. The women who escaped death due to medical or surgical interventions were categorized as Near Miss. These cases were defined based on WHO Criteria 2009.Results: There were 2424 births during this year and 33 were near miss cases. The bulk of these were directly admitted to our hospital (23 cases). The most common condition leading to this dreadful condition was hemorrhage, acute severe hypertensive disorder (preeclampsia/eclampsia) and sepsis. Disseminated Intravascular Coagulation was found to be the most common organ dysfunction. Emergency hysterectomy was the most frequent surgical intervention used to prevent mortality.Conclusion: Maternal Near Miss review is a viable review as it has potential to highlight the deficiency as well as positive elements of obstetric services in any health system. Hemorrhage followed by hypertensive disorders are the leading causes of near miss events.Med Phoenix Vol.2(1) July 2017, 44-47

Examining the Effects of Near Miss Events in the Humanitarian Newsvendor Context

We investigate a humanitarian newsvendor’s pre-positioning decisions in the context of near miss events where the event of interest is a near stock-outs. Results from a laboratory study show that near stock-outs that are not accompanied by salient warnings regarding the threat of a stock-out lead to normatively inappropriate decreases in pre-positioned stock, corresponding to an increase in risk-taking behavior in future decisions, adding a novel bias to the literature on newsvendor decisions. Moreover, initial increases in risk-taking following near stock-outs are strongest for decision makers with a predominant focus on avoiding excess inventory as opposed to preventing stock-outs. In the case of repeated experiences of near stock-outs, we witness decreases in risk taking behaviors for near stock-outs with salient cues of the potential danger involved, as well as for those decision makers who primarily focused on excess inventory. Our study provides clear implications for practice, where unwarranted inc...

Erratum to: The Effect of Losses Disguised as Wins and Near Misses in Electronic Gaming Machines: A Systematic Review.

Near misses and losses disguised as wins have been of interest to gambling researchers and policymakers for many years (e.g., Griffiths in J Gambl Stud 9(2):101–120, 1993). This systematic literature review describes the behavioural, psychological, and psychobiological effects of near misses and losses disguised as wins (LDWs) in an effort to evaluate their precise influence on the player and to highlight areas requiring further investigation. A systematic search for relevant studies was conducted using Scopus, PubMed, PsycINFO, ProQuest Sociology databases, and the Gambling Research Exchange Ontario Knowledge Repository. A total of 51 (from an initial pool of 802) experimental peer-reviewed studies using human participants were found between 1991 and 2015. The systematic review revealed that near misses motivate continued play, but have varying effects on the emotional state or betting behaviour of the player. Near miss events were also shown to be associated with elevated skin conductance levels and diffuse activity across the brain, most consistently in areas processing reinforcement and reward. Re-examination of the studies of near misses events after classifying the type of game feedback suggested that the effectiveness of near misses is related to the phenomenology of a near miss itself rather than as a response to auditory or visual feedback provided by a slot machine. In contrast to near misses, the presence of LDWs was found to relate to an overestimation of how much a player is actually winning and was consistently viewed as an exciting event. The effect of LDWs appears to be driven by the presence of visuals and sounds most often associated with a true win. Practical implications and directions for future research are also discussed.

"How Near Miss Events Affect Risk Taking: The Role of Congruence, Salience and Regulatory Focus"

Recent studies have shown that experiencing near miss events can lead to inconsistent risk perceptions and biased decision making. However, existing research in the management literature is limited...

'Whew that was Close!' How Near Miss Events Bias Subsequent Decision Making under Risk

In two experiments, we show clear evidence of a 'near miss' bias, in that when people receive information about prior near miss events (events that could have had a positive or negative outcome, where the outcome was non-fatal) they subsequently make riskier decisions than those who receive no near miss information. We explain the near miss bias as a discounting of given probability information such that people fail to see the independence of events. In Experiment 2, we show that when probability information is made salient and the decision makers attend to this probability information as the basis for their decision, the near miss bias goes away. In Experiment 2, we also see that when people have near miss information they search significantly less for information, even when that information is costless. Results are discussed in terms of accident prevention, Bayesian updating, and the normalization of deviance.

Sudden Infant Death: Near Miss Events and Sleep Research. Some Recommendations to Improve Comparability of Results Among Investigators

Sudden Infant Death: Near Miss Events and Sleep Research. Some Recommendations to Improve Comparability of Results Among Investigators