Clinical risk management in obstetrics.
OBJECTIVE
Over recent years there has been a growing appreciation that a small but significant proportion of patients experience (sometimes serious) adverse events in the hands of health care workers. Although research in this area is very much in its infancy there has been an increasing move towards applying principles of risk management from industry to health care organizations. With the particularly disastrous and costly nature of adverse outcomes in obstetrics it is appropriate to review clinical risk management issues in maternity.


RESULTS
This review explores the appropriateness of applying lessons learned in industry to maternity. The classification of errors into individual and latent, or organizational, is examined. Furthermore, the way in which these errors can be identified and subsequently analysed, with examples from maternity units in the UK and USA, is discussed. The importance of an educational and supportive environment, rather than a blame culture, for both reporting of incidents and learning from adverse outcomes is emphasized.


CONCLUSIONS
Improvement in patient experience of health care rests not just with improved treatments, but also with a reduction in the adverse events which occur in health care institutions. The principles by which risk can be identified prospectively and retrospectively, and the mechanisms for both local risk management and regional/national reporting and learning are considered.
Holden
Deborah A
DA
Maternity Unit, Brighton and Sussex University Hospitals NHS Trust, Royal Sussex County Hospital, Brighton, UK.
Quin
Maureen
M
Holden
Des P
DP
D005260:Female; D006801:Humans; D007049:Iatrogenic Disease / Q000517:prevention & control*; D019300:Medical Errors / Q000517:prevention & control*; D009774:Obstetrics / Q000379:methods / Q000592:standards*; D009775:Obstetrics and Gynecology Department, Hospital / Q000592:standards* / Q000706:statistics & numerical data; D011247:Pregnancy; D012307:Risk Factors; D012308:Risk Management / Q000706:statistics & numerical data*; D006113:United Kingdom