Critical incident audit and feedback to improve perinatal and maternal mortality and morbidity

Abstract

Background Audit and feedback of critical incidents is an established part of obstetric practice. However, the effect on perinatal and maternal mortality is unclear. The potential harmful effects and costs are unknown. Objectives Is critical incident audit and feedback effective in reducing the perinatal mortality rate, the maternal mortality ratio, and severe neonatal and maternal morbidity? Search methods We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (30 November 2010) and the Cochrane Effective Practice and Organisation of Care Group’s Trials Register (18 November 2010). Selection criteria Randomized trials of audit (defined as any summary of clinical performance over a specified period of time) and feedback (method of feeding that information back to the clinicians) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes. Data collection and analysis No suitable trials were found. Main results None. Authors’ conclusions The necessity of recording the number and cause of deaths is not in question. Mortality rates are essential in identifying problems within the healthcare system. Maternal and perinatal death reviews should continue to be held, until further information is available. The evidence from serial data clearly suggests more benefit than harm. Feedback is essential in any audit system. The most effective mechanisms for this are unknown, but it must be directed at the relevant people.

Barriers and facilitators to maternal death surveillance and response at a busy urban National Referral Hospital in Uganda

“…This study revealed failure to complete the MDSR cycle, characterized by not implementing actions from death reviews as a key barrier. In line with our findings, other studies have noted that the MDSR cycle must be completed by implementing actions in order to trigger iterative cycles of improvement as a culture of success to improve outcomes ( Bandali et al , 2016 ; Kinney et al , 2020 ; Lewis, 2014 ; Moodley et al , 2014 ; Pattinson et al , 2005 ). Notwithstanding, is the importance of a holistic approach to weave in the various health system building blocks recommended by World Health Organization (WHO) to improve quality of health care to reduce deaths.…”

Barriers and facilitators to maternal death surveillance and response at a busy urban National Referral Hospital in Uganda

“…This study revealed failure to complete the MDSR cycle, characterized by not implementing actions from death reviews as a key barrier. In line with our findings, other studies have noted that the MDSR cycle must be completed by implementing actions in order to trigger iterative cycles of improvement as a culture of success to improve outcomes ( Bandali et al , 2016 ; Kinney et al , 2020 ; Lewis, 2014 ; Moodley et al , 2014 ; Pattinson et al , 2005 ). Notwithstanding, is the importance of a holistic approach to weave in the various health system building blocks recommended by World Health Organization (WHO) to improve quality of health care to reduce deaths.…”

Impact of maternal death reviews at a rural hospital in Zambia: a mixed methods study

“…Maternal deaths were 35% lower after MDR was implemented compared to the period before its implementation, similar to results of other before-and-after studies of MDR in sub-Saharan Africa [ 11 , 12 ]. Inpatient maternal deaths fell from 23 per thousand live births to 8 per thousand.…”

Exploring the sustainability of perinatal audit in four district hospitals in the Western Cape, South Africa: a multiple case study approach

“…Our study validates the need for tangible system inputs, such as focal points and regular meetings,5 6 29–33 and shows that for sustainability, integrating these into routine practice and systems gives people the capability to sustain implementation. Organisational incentives (refreshments, per diems and continuous professional development points) did not appear to contribute to sustained participation in our study, though incentives have been identified in other settings 6 34…”

Barriers and facilitators to maternal death surveillance and response at a busy urban National Referral Hospital in Uganda

“…This study revealed failure to complete the MDSR cycle, characterized by not implementing actions from death reviews as a key barrier. In line with our findings, other studies have noted that the MDSR cycle must be completed by implementing actions in order to trigger iterative cycles of improvement as a culture of success to improve outcomes ( Bandali et al , 2016 ; Kinney et al , 2020 ; Lewis, 2014 ; Moodley et al , 2014 ; Pattinson et al , 2005 ). Notwithstanding, is the importance of a holistic approach to weave in the various health system building blocks recommended by World Health Organization (WHO) to improve quality of health care to reduce deaths.…”

Impact of maternal death reviews at a rural hospital in Zambia: a mixed methods study

“…Maternal deaths were 35% lower after MDR was implemented compared to the period before its implementation, similar to results of other before-and-after studies of MDR in sub-Saharan Africa [ 11 , 12 ]. Inpatient maternal deaths fell from 23 per thousand live births to 8 per thousand.…”

Exploring the sustainability of perinatal audit in four district hospitals in the Western Cape, South Africa: a multiple case study approach

“…Our study validates the need for tangible system inputs, such as focal points and regular meetings,5 6 29–33 and shows that for sustainability, integrating these into routine practice and systems gives people the capability to sustain implementation. Organisational incentives (refreshments, per diems and continuous professional development points) did not appear to contribute to sustained participation in our study, though incentives have been identified in other settings 6 34…”

Barriers and facilitators to maternal death surveillance and response at a busy urban National Referral Hospital in Uganda

“…This study revealed failure to complete the MDSR cycle, characterized by not implementing actions from death reviews as a key barrier. In line with our findings, other studies have noted that the MDSR cycle must be completed by implementing actions in order to trigger iterative cycles of improvement as a culture of success to improve outcomes ( Bandali et al , 2016 ; Kinney et al , 2020 ; Lewis, 2014 ; Moodley et al , 2014 ; Pattinson et al , 2005 ). Notwithstanding, is the importance of a holistic approach to weave in the various health system building blocks recommended by World Health Organization (WHO) to improve quality of health care to reduce deaths.…”

Impact of maternal death reviews at a rural hospital in Zambia: a mixed methods study

“…Maternal deaths were 35% lower after MDR was implemented compared to the period before its implementation, similar to results of other before-and-after studies of MDR in sub-Saharan Africa [ 11 , 12 ]. Inpatient maternal deaths fell from 23 per thousand live births to 8 per thousand.…”

Exploring the sustainability of perinatal audit in four district hospitals in the Western Cape, South Africa: a multiple case study approach

“…Our study validates the need for tangible system inputs, such as focal points and regular meetings,5 6 29–33 and shows that for sustainability, integrating these into routine practice and systems gives people the capability to sustain implementation. Organisational incentives (refreshments, per diems and continuous professional development points) did not appear to contribute to sustained participation in our study, though incentives have been identified in other settings 6 34…”