Patient Safety, Adverse Healthcare Events and Near-Misses in Obstetric Care —A Systematic Literature Review


Systematic development of a patient safety culture is necessary because lack of quality care leads to human suffering. The aim of this review was to identify evidence of obstetric adverse events (AEs) and near-misses in the context of patient safety. We conducted a search of the published literature from Europe, Australia and the USA in the following databases: Cinahl, Cochrane, Maternity and Infant Care, Ovid, Pro-quest and PubMed, guided by PRISMA procedures. A total of 427 studies were screened, 15 full papers retrieved and nine studies included in the final thematic analysis. The selected papers address a broad spectrum of adverse patient safety events in obstetric care. The themes that emerged were: type of AEs, near-misses and their consequences, strategies to support and improve Patient Safety (PS) and domains related to the WHO Patient Safety competence outcomes. The findings of the first theme were grouped into the following categories: healthcare professionals’ perspectives on ethical conflicts, attributing blame and responsibility, and patients’ perspectives on lack of trust and involvement, as well as medication errors. The second theme, strategies to support interventions to improve PS, was based on two sub-themes: communicating effectively and gaining competence by learning from adverse events, while the third theme was domains related to the WHO Patient Safety competence outcomes. In conclusion, few studies have examined strategies for managing AEs despite the existence of programmes that target the implementation of changes, such as improved teamwork training. In addition to exploring strategies to make safety a priority for patients and healthcare professionals, it is of the utmost importance to improve communication with patients and between professionals in order to maintain and enhance safety. Efforts by organizations and individuals to continuously develop knowledge about the risk of AEs and the use of best practice guidelines are also essential.

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Severinsson, E. , Haruna, M. , Rönnerhag, M. and Berggren, I. (2015) Patient Safety, Adverse Healthcare Events and Near-Misses in Obstetric Care —A Systematic Literature Review. Open Journal of Nursing, 5, 1110-1122. doi: 10.4236/ojn.2015.512118.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Lindsay, P. (2014) Maternity Support Workers and Safety in Maternity Care in England. The Practising Midwife, 17, 20-22.
[2] Sammer, C., Lykens, K., Singh, K., Mains, D. and Lackan, N. (2012) What Is Patient Safety Culture? A Review of the Literature. Journal of Nursing Scholarship, 42, 156-165.
[3] Kohn, L., Corrigan, J. and Donaldson, M., Eds. (2000) To Err Is Human: Building a Safer Health System. Committee on Quality of Healthcare in America, Institute of Medicine, National Academy Press, Washington DC.
[4] Taylor, L.S., Dy, S., Foy, R., Hempel, S., McDonald, K.M., Ovretveit, J., Pronovost, P.J., Rubenstein, L.V., Wachter, R.M. and Shekelle, P.G. (2012) What Context Features Might Be Important Determinants of the Effectiveness of Patient Safety Practice Interventions? BMJ QualitySafety, 20, 611-617.
[5] Milligan, F. and Dennis, S. (2005) Building a Safety Culture. Nursing Standard, 23, 48-52.
[6] Hasley, S.K. (2011) Decision Support and Patient Safety: The Time Has Come. American Journal of Obstetrics and Gynecology, 204, 461-465.
[7] Madden, I. and Milligan, F. (2004) Enhancing Patient Safety and Reporting Near Misses. British Journal of Midwifery, 12, 643-647.
[8] Department of Health (2001) Building a Safer NHS for Patients: Implementation an Organisation with a Memory. The Stationary Office, London.
[9] Say, L., Souza, J. P., Pattinson, R.C., et al. (2009) Maternal Near Miss-Towards a Standard Tool for Monitoring Quality of Maternal Health Care. Best Practice & Research Clinical Obstetrics and Gynaecology, 23, 287-296.
[10] Khan, S.K., Wojdyla, D., Say, L., Gülmezoglu, M.A. and Van Look, P. (2006) WHO Analysis of Causes of Maternal Death: A Systematic Review. The Lancet, 367, 1066-1074.
[11] World Health Organization (2014) Safe Childbirth Checklist Collaboration: Improving the Health of Mothers and Neonates.
[12] Renfrew, M.J., McFadden, A., Bastos, M.H., Campell, J., Channon, A.A., Cheung, F.N., Delage Silva, D.R.A., Downe, S., Kennedy, H.P., Malata, A., McCormick, F., Wick, L. and Declercq, E. (2014) Midwifery and Quality Care: Findings from a New Evidence-Informed Framework for Maternal and Newborn Care. The Lancet, 384, 1129-1145.
[13] Ten Hoope-Bender, P., de Bernis, L., Campell, J., Downe, S., Fauveau ,V., Fogstad, H., Homer, C., Kennedy, P.H., Matthews, Z., McFadden, A., Renfrew, M.J. and Van Lerberghe, W. (2014) Improvement of Maternal and Newborn Health through Midwifery. The Lancet, 384, 1226-1235.
[14] Vincent, C. (2003) Understanding and Responding to Adverse Events. The New England Journal of Medicine, 348, 1051-1056.
[15] Régo, P., Lyon, P. and Watson, M. (2011) The Impact of Maternity Crisis Resource Management Training. British Journal of Midwifery, 19, 315-323.
[16] World Health Organization (2008) International Classification for Patient Safety for Use in Field Testing in 2007-2008. Geneva.
[17] World Health Organization (WHO) (2009) Download the WHO Patient Safety Curriculum Guide for Medical Schools.
[18] World Health Organization (WHO) (2011) Public Health Surveillance.
[19] World Health Organization (WHO) (2011) The WHO Near-Miss Ap-proach.
[20] Peters, D., Tran, N.T. and Adam, T. (2013) Implementation Research: What It Is and How to Do It. BMJ, 347, f6753.
[21] Moher, D., Liberati, A., Tetzlaff, J., Altman, D. and The PRISMA Group (2009) Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. International Journal of Surgery, 8, 336-341.
[22] Allen, S., Chiarella, M. and Homer, C. (2010) Lessons Learned from Measuring Safety Culture: An Australian Case Study. Midwifery, 26, 497-503.
[23] Lawton, R., Gardner, P. and Plachcinski, R. (2010) Using Vignettes to Explore Judgements of Patients about Safety and Quality of Care: The Role of Outcome and Relationship with the Care Provider. Health Expectations, 14, 296-306.
[24] Gephart, S.M., McGrath, J.M. and Effken, J.A. (2011) Failure to Rescue in Neonatal Care. The Journal of Perinatal & Neonatal Nursing, 25, 275-282.
[25] Kfuri, T.A., Morlock, L., Hicks, R. and Shore, A.D. (2008) Medication Errors in Obstetrics. Clinics in Perinatalogy, 35, 101-117.
[26] Scholefield, H. (2007) Embedding Quality Improvement and Patient Safety at Liverpool Women’s NHS Foundation Trust. Best Practice & Research Clinical Obstetrics & Gynaecology, 21, 593-607.
[27] Simpson, K.R., James, D.C. and Knox, E.G. (2006) Nurse-Physician Communication during Labor and Birth: Implications for Patient Safety. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 35, 547-556.
[28] Symon, A.G., McStea, B. and Murphy-Black, T. (2006) An Exploratory Mixed-Methods Study of Scottish Midwives’ Understanding and Perceptions of Clinical Near Misses in Maternity Care. Midwifery, 22, 125-136.
[29] Martijn, L., Jacobs, A., Amelink-Verburg, M., Wentzel, R., Buitendijk, S. and Wensing, M. (2013) Adverse Outcomes in Maternity Care for Women with a Low Risk Profile in the Netherland: A Case Serious Analysis. BMC Pregnancy and Childbirth, 13, 219.
[30] Currie, L. and Richens, Y. (2009) Exploring the Perceptions of Midwifery Staff about Safety Culture. British Journal of Midwifery, 17, 783-790.
[31] Barach, P. and Small, S.D. (2000) Reporting and Preventing Medical Mishaps: Lessons from Non-Medical near Miss Reporting Systems. BMJ, 320, 759.
[32] Delmar, C. (2012) The Excesses of Care: A Matter of Understanding the Asymmetry of Power. Nursing Philosophy, 13, 236-243.
[33] Amsrud, K., Lyberg, A. and Severinsson, E. (2015) Evaluation of Nursing Students’ Views of Improved Competence Development after Attending Clinical Supervision: An Educative Approach to the WHO Patient Safety Model. Open Journal of Nursing, 5, 725-734.
[34] Amsrud, E., Lyberg, A. and Severinsson, E. (2015) The Influence of Clinical Supervision and Its Potential for Enhancing Patient Safety-Undergraduate nursing Students’ Views. Journal of Nursing Education and Practice, 5, 87-95.
[35] Berggren, I. and Severinsson, E. (2003) The Nurse Supervisors’ Actions in Relation to Decision-Making and Their Ethical Approach in Clinical Nursing Supervision. Journal of Advanced Nursing, 41, 615-622.
[36] Lyberg, A. and Severinsson, E. (2010) Midwives’ Supervisory Styles and Leadership Role as Experienced by Norwegian Mothers in the Context of Fear of Childbirth. Journal of Nursing Management, 18, 391-399.
[37] Berggren, I., Bégat, I. and Severinsson, E. (2002) Australian Clinical Nurse Supervisors’ Ethical Decision-Making Style. Nursing & Health Sciences, 4, 15-23.
[38] Entwistle, V.A. and Watt, I.S. (2013) Treating Patients as Persons: A Capabilities Approach to Support Delivery of Person-Centered Care. The American Journal of Bioethics, 13, 29-39.
[39] Bélanger, L. and Ducharme, F. (2015). Narrative-Based Educational Nursing Intervention for Managing Hospitalized Older Adults at Risk for Dilerium: Field Testing and Qualitative Evaluation. Geriatric Nursing, 36, 40-46.
[40] Bird, D. (2005) Patient Safety: Improving Incident Reporting. Nursing Standard, 14, 43-46.
[41] Rooks, J. (1999) The Midwifery Model of Care. Journal of Nurse-Midwifery, 44, 370-374.
[42] Homer, C., Brodie, P. and Leap, N. (2008) Midwifery Continuity of Care—A Practical Guide. Elsevier, Chatswood.
[43] Sandall, J. (1997) Midwives’ Burnout and Continuity of Care. British Journal of Midwifery, 5, 106.
[44] Correa-Velez, I. and Ryan, J. (2012) Developing a Best Practice Model of Refugee Maternity Care. Women and Birth, 25, 13-22.
[45] Sandall, J., Soltani, H., Gates, S., Shennan, A. and Devane, D. (2008) Midwife-Led versus Other Models of Care for Childbearing Women. The Cochrane Collaboration, Issue No. 9., Wiley.
[46] Homer, C. Davis, G., Brodie, P., Sheehan, A., Barclay, L., Wills, J. and Chapman, M. (2001) Collaboration in Maternity Care: A Randomised Controlled Trial Comparing Community-Based Continuity of Care with Standard Hospital Care. British Journal of Obstetrics and Gynaecology, 108, 16-22.
[47] Waldenström, U. and Turbull, D. (1998) A Systematic Review Comparing Continuity of Care with Standard Maternity Services. British Journal of Obstetrics and Gyneacology, 105, 1160-1170.
[48] McCormack, B. and McCance, T. (2006) Development of a Framework for Person-Centred Nursing. Journal of Advanced Nursing, 56, 472-479.
[49] Vincent, C. (2003) Understanding and Responding to Adverse Events. The New England Journal of Medicine, 348, 1051-1056.
[50] Ofstad, H. (1961) An Inquiry into the Freedom of Decision. Norwegian Universities Press, Oslo.
[51] Moore, J.E., Low, L.K., Titler, M.G., Dalton, V.K. and Sampselle, C.M. (2014) Moving toward Patient-Centered Care: Women’s Decisions, Perceptions, and Experiences of the Induction of Labor Process. Birth, 41, 138-146.
[52] Barry, M.J. and Edgman-Levitan, S. (2012) Shared Decision Making—The Pinnacle of Patient-Centered Care. The New England Journal of Medicine, 366, 780-781.
[53] Moore, J.E., Titler, M.G., Kane Low, L., Dalton, V.K. and Sampselle, C.M. (2015) Transforming Patient-Centered Care: Development of the Evidence Informed Decision Making through Engagement Model. Women’s Health Issues, 25, 276-282.
[54] Higgens, J. and Green, S. (2005) Cochrane Handbook for Systematic Reviews of Interventions. The Cochrane Collaboration.
[55] Scholefield, H. (2005) Risk Management in Obstetrics. Current Obstetrics & Gynaecology, 15, 237-243.
[56] Maeda, S., Kamishiraki, E. and Sarkey, J. (2012) Patient Safety Education at Japanese Medical Schools: Results of a Nationwide Survey. BMC Research Notes, 5, 226.

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