title: Adverse outcomes in maternity care for women with a low risk profile in The Netherlands: a case series analysis.
abstract: BACKGROUND
  This study aimed to perform a structural analysis of determinants of risk of critical incidents in care for women with a low risk profile at the start of pregnancy with a view on improving patient safety.
  
  
  METHODS
  We included 71 critical incidents in primary midwifery care and subsequent hospital care in case of referral after 36 weeks of pregnancy that were related to substandard care and for that reason were reported to the Health Care Inspectorate in The Netherlands in 36 months (n = 357). We performed a case-by-case analysis, using a previously validated instrument which covered five broad domains: healthcare organization, communication between healthcare providers, patient risk factors, clinical management, and clinical outcomes.
  
  
  RESULTS
  Determinants that were associated with risk concerned healthcare organization (n = 20 incidents), communication about treatment procedures (n = 39), referral processes (n = 19), risk assessment by telephone triage (n = 10), and clinical management in an out of hours setting (n = 19). The 71 critical incidents included three cases of maternal death, eight cases of severe maternal morbidity, 42 perinatal deaths and 12 critical incidents with severe morbidity for the child. Suboptimal prenatal risk assessment, a delay in availability of health care providers in urgent situations, miscommunication about treatment between care providers, and miscommunication with patients in situations with a language barrier were associated with safety risks.
  
  
  CONCLUSIONS
  Systematic analysis of critical incidents improves insight in determinants of safety risk. The wide variety of determinants of risk of critical incidents implies that there is no single intervention to improve patient safety in the care for pregnant women with initially a low risk profile.
authors.affiliation: IQ healthcare, Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, 114 IQ healthcare, P,O, Box 9101, 6500, HB Nijmegen, The Netherlands. l.martijn@iq.umcn.nl.
authors.forename: Lucie
authors.initials: L
authors.lastname: Martijn
authors.forename: Annelies
authors.initials: A
authors.lastname: Jacobs
authors.forename: Marianne
authors.initials: M
authors.lastname: Amelink-Verburg
authors.forename: Renske
authors.initials: R
authors.lastname: Wentzel
authors.forename: Simone
authors.initials: S
authors.lastname: Buitendijk
authors.forename: Michel
authors.initials: M
authors.lastname: Wensing
mesh_terms: D039602:After-Hours Care / Q000592:standards; D003144:Communication Barriers; D005260:Female; D019983:Guideline Adherence; D006760:Hospitalization; D006801:Humans; D008427:Maternal Health Services / Q000592:standards*; D019300:Medical Errors / Q000009:adverse effects*; D008880:Midwifery / Q000592:standards*; D009426:Netherlands; D061214:Patient Safety; D011247:Pregnancy; D011248:Pregnancy Complications / Q000175:diagnosis / Q000628:therapy*; D011320:Primary Health Care / Q000592:standards*; D011787:Quality of Health Care; D012017:Referral and Consultation / Q000592:standards; D018570:Risk Assessment / Q000592:standards; D012307:Risk Factors; D061665:Time-to-Treatment; D014218:Triage / Q000592:standards