The report, by the Canadian Medical Protective Association (CMPA) and the Healthcare Insurance Reciprocal of Canada (HIROC), identifies contributing factors to patient safety incidents and offers mitigation strategies for providers and organizations. The review of 10 years of CMPA and HIROC obstetrical cases analyzes the shared top risk areas. Among the highlights of the report:
- The two highest shared risk areas are fetal heart rate monitoring and induction/augmentation of labour;
- System issues identified as having the greatest potential for positive impact; and,
- Mitigation strategies include strengthening clinical decision-making by providers, boosting team communication and bringing system issues to light.
Specifically, for those cases with an obstetrical incident, provider factors were found to be the largest category of contributing factors. Two major themes were provider decision-making, including a lack of situational awareness and team communication. System issues included inadequate processes and protocols, second-on-call contingency plans and resourcing issues.
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Un regard sur l'accouchement: consolider les soins obstétricaux au Canada - ACPM