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LR35 / Prevention of medication errors and surgical wound infections

Spain




Type of Patient Safety Practice
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Medication / IV Fluids
Patient safety theme the SCP/clinical risk management practice is aimed at
Medication errors and surgical wound infection are the most common adverse events in gynecology and obstetric units.
Objective of the CRM practice
To identify studies that analyze adverse events (AE) related to medical care in gynecology and obstetrics with the objective to identify the sources of adverse events [4].
Short description of the CRM practice, including any references for further information
Fifty-seven studies were selected. In 39.2% of deliveries an incident (defined as “occurrences that are not consistent with routine hospital operation or patient care”) was identified. There were 1.4 medication errors for every 1,000 hospital stays in obstetrics and 3.54 medication errors for every 1,000 medical orders in obstetrics and gynecology. The surgical wound infection rate after caesarean section oscillated from 1.5-11.2%. The rate of major complications (injuries to the urinary or digestive tracts or blood vessels) in gynecological surgery ranged from 0.14-0.4%. The rate of infectious complications oscillated from 2.2-22%, depending on the type of approach (lower in laparoscopy). The incidence of thromboembolic disease after gynecological surgery was 0.2-0.5%. A detailed knowledge of sources of adverse events allows assessment and continuous improvement, increasing safety. The elaboration of pathways of care reduces the number of adverse events in gynecology and Obstetric Units [4].
Innovator of the SCP, country of origin
This study was conducted in Spain but included results from 57 studies from several countries and context.

Involved health care staff
Gynecology and Obstetric healthcare staff
Tested in which countries/health care systems, health care context(s) and/or clinical specialty/specialties, including references
It’s a review of the scientific literature. A majority of studies from USA, UK and Canada.
Summary of evidence for effectiveness, including references
There is a scarcity of studies that specifically analyze the incidence of adverse events (AE) in gynecology and obstetrics. Incidents occur in 40% of deliveries. In gynecology the most frequent AE is postoperative infection. Detailed analysis of AE could identify areas for improvement and consequently diminish the incidence of AE [1] [2] [3].
Summary of evidence for transferability (transferability across health care systems or health care contexts or clinical specialties), including references
A review study of the scientific literature about AE in Gynecology and Obstetric from 1960 was carried out. Data were extracted from 57 studies conducted in several developed countries (a majority of them in USA, Canada, UK) and hospitals (both general and university hospitals) [4].
Summary of available information on feasibility, including references
Develop pathway of care is much more simple than to apply them in clinical practice. However, this review suggest that pathway of care implementation reduce the number of adverse events in Gynecology and Obstetrics [4].
Existing implementation tools, including references
None
Potential for/description of patient involvement in the CRM practice, including references
none
Bibliography (for each reference: author(s), year, title, journal/internet link, page(s))
[1] Michel P, Quenon JL, De Sarasqueta AM, Scemama O. Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals.
BMJ. 2004;328:199
[2] Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: case-control study. BMJ. 2001; 322:1089-93.
[3] Minkauskiene M, Nadisauskiene R, Padaiga Z, Makari S. Systematic review on the incidence and prevalence of severe maternal morbidity. Medicina (Kaunas). 2004;40:299-309
[4] Marta Padilla-Castillo, Eva Elisa Álvarez-León, Jesús María Aranaz-Andrés, Antonio Jiménez-Bravo de Laguna and Jose Ángel García-Hernández. A review of the gynecology and Obstetric adverse events. Rev Calidad Asistencial. 2005;20(2):90-9.
Reviewer
Prof. Jose Mira, Julián Vitaller and Jesús Aranaz. Universidad Miguel Hernandez
Organisation
Universidad Miguel Hernandez
Any additional information on the CRM (e.g. implementation barriers and drivers)
e.g. description of concrete national or regional experience in practice
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