Analysis of Adverse Events in the Department of Obstetrics and Gynecology, Cipto Mangunkusumo Hospital, in 2015
IPG Kayika, Lucas Christiawan, Atikah Sayogo Putri
Adverse events, Public service coordinator, Quality committee of patient safety and performance, Root cause analysis
Citation Information :
Kayika I, Christiawan L, Putri AS. Analysis of Adverse Events in the Department of Obstetrics and Gynecology, Cipto Mangunkusumo Hospital, in 2015. J South Asian Feder Obs Gynae 2021; 13 (1):6-10.
Background: Medical errors are a serious threat for they can lead to injury and death of the patients, as well as increased healthcare cost. According to the Institute of Medicine 2000 report, there were 3 to 16% of adverse events (AEs) occurred in inpatient care in United States, Denmark, United Kingdom, and Australia. However, AEs data in Indonesia is still limited. This study aimed to identify the distribution of AEs in the Department of Obstetrics and Gynecology (Ob-gyn) of Cipto Mangunkusumo Hospital based on locations, contributing factors, failure to prevent the occurrence, and additional length of stay.
Materials and methods: Cross-sectional study was conducted towards AEs occurring in the Department of Ob-gyn of Cipto Mangunkusumo Hospital during January to December 2015. Data were obtained from Public Service Coordinator which had been clinically audited with the root cause analysis method.
Results: During 2015, 36 AEs were reported, followed by a clinical audit by clinical risk management team. Twenty-four cases were included in this study. Based on the location, 13 (54%) cases occurred in the emergency room (ER), 4 (17%) in intensive care unit (ICU), 4 (17%) in operation theatre, and 3 (12%) in the hospital ward. Based on the contributing factor, 18 cases (75%) were due to lack of knowledge and skill of the medical personnel, 4 (17%) were due to other causes, and 2 (33%) were due to technical error. Based on the failure to prevent the occurrence, there were eight cases (33%) of delayed medical care or intervention, six (25%) of malpractice, five (21%) of misdiagnosis, three (13%) of failure to act based on test results, and two (8%) of failure to take precautions. The median of additional length of stay was of 2 days (0–34 days; 95% CI).
Conclusion: Most of AEs in Department of Ob-gyn of Cipto Mangunkusumo Hospital, in 2015 occurred in ER (54%). The most frequent cause was lack of knowledge and skill of the medical personnel (75%), with delayed medical care or treatment as the most frequent failure to prevent the occurrence (33%).
Richardson WC, Bisgard JC, Bristow LR, et al. To err is human: building a safer health system. United States: Institute of Medicine; 1999.
PERSI. Buku Panduan Nasional Keselamatan Pasien Rumah Sakit (Patient Safety). Jakarta: Departemen Kesehatan Republik Indonesia; 2006.
Mendes W, Pavao AL, Martins M, et al. The feature of preventable adverse events in hospitals in the State of Rio de Janeiro, Brazil. Rev Assoc Med Bras 2013;59(5):421–428. DOI: 10.1016/j.ramb.2013.03.002.
Murray-Davis B, McDonald H, Cross-Sudworth F, et al. Learning from adverse events in obstetrics: is a standardized computer tool an effective strategy for root cause analysis? J Obstet Gynaecol Can 2015;37(8):728–735. DOI: 10.1016/S1701-2163(15)30178-X.
Peraturan Menteri Kesehatan Republik Indonesia Keselamatan Pasien Rumah Sakit, Nomor 1691/MENKES/PER/VIII/2011. Sect. III; 2011.
Yully HM. Analisis Determinan Kejadian Nyaris Cedera dan Kejadian Tidak Diharapkan di Unit Perawatan Rumah Sakit Pondok Indah Jakarta. Depok, Jawa Barat: Universitas Indonesia; 2011.
Sabrina D. Kajian Operasional Laporan Insiden RSCM Tahun 2015. RSUPN dr Cipto Mangunkusumo: Komite Mutu, Keselamatan Pasien, dan Kinerja; 2019.
Friedman SM, Moore S, Provan D, et al. Errors, near misses and adverse events in the emergency department: what can patients tell us? CJEM 2008;10(5):421–427. DOI: 10.1017/s1481803500010484.
Forster AJ, Fung I, Caughey S, et al. Adverse events detected by clinical surveillance on an obstetric service. Obstet Gynecol 2006;108(5):1073–1083. DOI: 10.1097/01.AOG.0000242565.28432.7c.
Murff HJ, Patel VL, Hripcsak G, et al. Detecting adverse events for patient safety research: a review of current methodologies. J Biomed Inform 2003;36(1–2):131–143. DOI: 10.1016/j.jbi.2003.08.003.
Geurden B, Wouters C, Franck E, et al. Does documentation in nursing records of nutritional screening on admission to hospital reflect the use of evidence-based practice guidelines for malnutrition? Int J Nurs Knowledge 2014;25(1):43–48. DOI: 10.1111/2047-3095.12011.
Law L, Akroyd K, Burke L. Improving nurse documentation and record keeping in stoma care. Br J Nurs 2010;19(21):1328–1332. DOI: 10.12968/bjon.2010.19.21.80002.
Lyons PG, Arora VM, Farnan JM. Adverse events and near-misses relating to intensive care unit–ward transfer: a qualitative analysis of resident perceptions. Ann Am Thorac Soc 2016;13(4):570–572. DOI: 10.1513/AnnalsATS.201512-789LE.
Bari A, Khan RA, Rathore AW. Medical errors; causes, consequences, emotional response, and resulting behavioral change. Pak J Med Sci 2016;32(3):523–528. DOI: 10.12669/pjms.323.9701.
Weingart SN, Pagovich O, Sands DZ, et al. What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents. J Gen Intern Med 2005;20(9):830–836. DOI: 10.1111/j.1525-1497.2005.0180.x.