Analysis of adverse events in the department of obstetrics and gynecology, cipto mangunkusumo hospital, in 2015

Abstract

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%).