90: The frequency of and factors associated with adverse events on labor & delivery


      To estimate the frequency of adverse events on a labor and delivery unit and discern whether there are particular patient factors that predict their occurrence.

      Study Design

      This was a prospective cohort study of a labor & delivery unit at a tertiary care medical center. All patients admitted during rotating 8-hour periods each day over a 6-week period were eligible for the analysis. A trained observer was present on the unit to monitor for the occurrence of predefined trigger events that served to signal the increased likelihood of a quality problem (defined as an adverse event or potential adverse event). A three person multi-disciplinary team evaluated each trigger event and determined by consensus not only whether it was an adverse event or potential adverse event, but also the event’s preventability or potential to cause harm, respectively. An example of an adverse event is an intra-operative injury and an example of a potential adverse event is a delay in drug delivery. The frequency of adverse events and potential adverse events was determined and their association with patient factors estimated.


      The study included 213 patients admitted to L&D. Twenty-eight patients (13%) were determined by the multidisciplinary team to have had an adverse event and 18 (8%) were classified as experiencing a potential adverse event. Most adverse events (N = 23) were judged to be related to the patients’ underlying conditions or natural progression of disease, although 5 events (i.e., 17% of adverse events) were judged to be related to healthcare management and to have been preventable. Of potential adverse events, 51% were judged to have the potential to cause harm. No patient factors (Table) were found to be associated with adverse or potential adverse events (P > .05 for all).


      Adverse events or potential adverse events occurred in approximately 1 in 5 women admitted to a labor and delivery unit. No factors were found that identified which women were more likely to experience a quality problem.