title: [Adverse events related to care in obstetric units].
abstract: BACKGROUND
  The aim of the present investigation was to uncover whether adverse events related to care in obstetric units have been preceded by specific health care conditions, and whether such causal relations could be classified into general categories.
  
  
  METHODS
  The data cover 47 supervision cases within the area of pregnancy--and birth care. The cases were handled by the Norwegian Board of Health centrally (n = 32) and the Norwegian Board of Health in the counties (n = 15) in the period 2003-2006.
  
  
  RESULTS
  Several conditions caused the adverse events. They could be classified into the four main categories: communication--and cooperation failure, uncertain lines of responsibility, lack of qualification, and weaknesses in the organization. The examination of the material disclosed that at least 2/3 of the adverse event causes could be traced back to organization of the facility and uncertain lines of responsibility.
  
  
  CONCLUSIONS
  The causes of adverse events in obstetric units are often due to circumstances over which the individual health care personnel had no control. The classification of causes into four main categories can be used as a supplement tool in the internal improvement process at departments of obstetrics.
authors.affiliation: Helsetilsynet i Oslo og Akershus, Postboks 8111 Dep, 0032 Oslo. bente.kristin.johansen@kunnskapssenteret.no
authors.forename: Bente Kristin
authors.initials: BK
authors.lastname: Johansen
authors.forename: Brynhild
authors.initials: B
authors.lastname: Braut
authors.forename: Petter
authors.initials: P
authors.lastname: Schou
mesh_terms: D002983:Clinical Competence; D003142:Communication; D005260:Female; D005323:Fetal Monitoring / Q000592:standards; D006801:Humans; D007400:Interprofessional Relations; D019300:Medical Errors / Q000517:prevention & control / Q000706:statistics & numerical data; D009664:Norway; D007744:Obstetric Labor Complications / Q000175:diagnosis / Q000628:therapy; D009775:Obstetrics and Gynecology Department, Hospital / Q000458:organization & administration / Q000592:standards; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011248:Pregnancy Complications / Q000175:diagnosis / Q000628:therapy; D011369:Professional-Patient Relations; D011785:Quality Assurance, Health Care; D012307:Risk Factors; D012308:Risk Management; D016216:Ultrasonography, Prenatal / Q000592:standards