title: Investigating adverse outcomes in obstetrics.
abstract: Investigation of adverse outcomes in health care requires a systematic and systemically oriented approach. This is true in obstetrics where, in Western countries such as Canada, adverse outcomes in the form of maternal mortality are rare. A model for such investigation is presented, based on answers to 3 questions: What? How? and Why? These questions correspond to Donabedian's 3 components of quality assurance: Outcome, Process, and Structure, respectively. Aspects of Reason's model of accidents are also included, in the form of "active failures" and "latent conditions." The latter are divided into 5 basic contributory factors, 4 of which are derived from Helmreich's model of human factors influencing behaviour in flight-crew environments. To illustrate its basic nature, the model is applied to a previously well-investigated air crash at Dryden, Ontario, and 3 obstetric cases of maternal mortality. Application of the model to the reactive investigation of close calls is discussed, as is application to the proactive interrogation of the system for the presence and nature of hazards that pose threats to safety.
authors.affiliation: Department of Anesthesia, University of Calgary, Calgary Health Region, Calgary, AB, Canada.
authors.forename: Jan M
authors.initials: JM
authors.lastname: Davies
authors.forename: Ian R
authors.initials: IR
authors.lastname: Lange
mesh_terms: D002170:Canada; D036861:Delivery, Obstetric / Q000009:adverse effects / Q000592:standards*; D005260:Female; D006801:Humans; D008427:Maternal Health Services / Q000592:standards; D009774:Obstetrics / Q000592:standards*; D010043:Outcome and Process Assessment, Health Care; D011247:Pregnancy; D011785:Quality Assurance, Health Care