Bielorus A. I.

SOCIAL MEDICINE AND ORGANIZATION OF HEALTHCARE PROTECTION

Scentific article

According to the researches, up to 1-4% of births are complicated by adverse events, of which up to 2/3 can be considered reversible. Several research programs and initiatives have shown that up to half of cases associated with bleeding, hypertension, infection and thromboembolic conditions, which are the leading causes of severe morbidity and mortality of mothers, can be avoided. The main source of information on adverse events and errors in medicine is a special reporting system on medical incidents, the purpose of which is to obtain the information necessary for establishing feedback and effective management of risks. The aim of the study is to substantiate and develop the model for detection and prevention of adverse events in perinatal practice. To achieve this aim, content analysis and methods of system analysis and system approach were applied. Research results. The model for detection and prevention of adverse events in perinatal practice was substantiated. Its central element is the triad: the woman, the child and their family. The model includes 4 main components: a) establishment of already known barriers aimed at reducing the frequency of medical errors; b) detection of adverse events and reporting, which may be mandatory and voluntary, using a set of prospective and retrospective instruments; c) finding out the primary reason of the adverse event by analyzing the root cause, the “fish spine” methodology and perinatal audit by the interdisciplinary team; d) management of the newly detected risks in perinatal practice in the following categories: “team work and perinatal counseling”, “interdisciplinary and interprofessional communication”, “patient safety culture”, “infection control system”, “check-lists and package decisions”, “training and improvement of competence”, “the department’s inspection in terms of patient safety by the head and senior medical nurse of the department”. The content of tools for detecting adverse events and related errors has been substantiated and developed, including the list of perinatal sentinel events, near misses, the perinatal and neonatal trigger tool, as well as the template for voluntary medical reporting. To analyze adverse events in developed countries, one can apply the root cause analysis (RCA). The ultimate purpose of investigation is not the search and punishment of the culprit, but the identification of ways and the development of specific solutions to improve the system, the implementation of which eliminates or significantly minimizes the risks and the likelihood of a recurrent event in the future. Other methods include: “Ishikawa Chart” or “Fishbone Diagram” – a graphical way of studying the causal relationships between factors and implications in the situation under investigation or a problem that resembles a skeleton of fish; “Failure Mode and Effects Analysis” (FMEA) – a procedure that analyzes all possible errors in the implementation of new process and the “five whys analysis” – an interactive technique consisting of a series of five (sometimes more) sequential questions that is used to find out the causal relationships that underlie a particular problem. Conclusions. To minimize the occurrence of adverse events, a systematic and well-planned approach should be used. Leaders of perinatal medicine should be aware of the basic elements of the science on patient safety and the basic organizational tools for detecting and preventing the development of adverse events in perinatal practice.

adverse events, perinatal practice, model, detection, prevention, incident reporting, risk management

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«Bulletin of problems biology and medicine» Issue 2 (144), 2018 year, 335-340 pages, index UDK 618.2 / 7 + 616-053.31 / 34]: 616-036.11: 616-07

10.29254/2077-4214-2018-2-144-335-340