The Ottawa Hospital Quality Incident Notification System for Capturing Adverse Events in Obstetrics

Implementation of an Interprofessional Team Review of Adverse Events in Obstetrics Using a Standardized Computer Tool: A Mixed Methods Study

“…The generation of a plan for action or education is a recognized step in closed-loop communication strategies and is a key component of patient safety initiatives. 13 Non-punitive action plans and timely and meaningful feedback of learning plans have been shown to improve incident reporting. 19 Health care providers who perceive the system of reporting and feedback as safe, non-blaming, and likely to result in quality improvement are more likely to report incidents.…”

Learning from Adverse Events in Obstetrics: Is a Standardized Computer Tool an Effective Strategy for Root Cause Analysis?

“…Although adverse outcomes are rare, near misses and systems issues occur in up to 26% of births. 13 Many poor outcomes are potentially avoidable, but the current process of RCA of near miss or adverse events does not ensure proper identification of either key issues or learning and action points for clinicians. 16 Our pilot of the SCOR tool is one of the first standardized computer applications designed for review of adverse events in obstetrics in Canada.…”

“…8 Standardized mechanisms for both identification of the cases requiring review and for conducting the review to identify risk factors and recommendations for action are critical to this process. 2,6,[9][10][11][12][13] There is evidence that systematic formal case reviews have a positive impact on the patient safety culture at an institution and on decreasing the rates of adverse events. 14 A systematic review of interventions aimed at behaviour change within obstetrical practice demonstrated a positive impact of "audit and feedback" techniques in changing practice.…”

Quality Indicators for Continuous Monitoring to Improve Maternal and Infant Health in Maternity Departments: A Modified Delphi Survey of an International Multidisciplinary Panel

“…[14] Another method, the quality incident notification system, proved able to capture a relatively low rate of obstetrical adverse events in obstetrical care, about half of which were avoidable. [47] This system could be widely used for quality improvement initiatives in obstetric care.…”