Reporting on potentially avoidable deaths Lynn Sadler Epidemiologist
Reporting on potentially avoidable deaths Lynn Sadler Epidemiologist PMMRC
AIMS • To go beyond rates and descriptive data • To inform quality improvement
METHODOLOGY • Development of a data collection tool • Use of the tool in the review process • Audit and reporting of data
Development of a data collection tool • Developed iteratively from previous tools for perinatal and maternal mortality • Previous tools include combinations of: – Systems factors, including environment, technology, organisation and management – Personnel factors – Patient factors • Definitions: – Contributory factors – Potential avoidability/preventability
The PMMRC Tool Developed for assessment of preventability in maternal and perinatal mortality Domains: – organisation or management – technology and equipment – the environment – personnel – barriers to access or engagement with care
Have organisational or management factors been identified? • Including but not limited to: – – – – – Poor organisational arrangements of staff Inadequate education and training Lack of policies/protocols/guidelines Inadequate numbers of staff Poor access to senior clinical staff Failure or delay in emergency response Delay in procedure Delayed access to test results or inaccurate results Other, please state. .
Have technology and equipment factors been identified? • Including but not limited to: – – – Essential equipment not available Lack of maintenance of equipment Malfunction/failure of equipment Failure/lack of information technology Other, please state…
Have environmental factors been identified? • Including but not limited to: – Geography eg long transfer – Building and design functionality limited clinical response – Other, please state…
Have factors relating to personnel been identified? • Including but not limited to: – – – – Knowledge and skills of staff were lacking Delayed emergency response by staff Failure to maintain competence Communication between staff was inadequate Failure to seek help/supervision Failure to follow recommended best practice Lack of recognition of complexity or seriousness of condition by caregiver – Other, please state…
Have barriers to accessing or engaging with care been identified? • Including but not limited to: – Substance use – Family violence – Lack of recognition by the woman or family of the complexity or seriousness of condition – Maternal mental illness – Cultural barriers – Language barriers – Not eligible to access free care – Other, please state. .
Was the death potentially avoidable? • Yes • No
Introduction of the tool for perinatal death • Concept introduced in 2008 • Training at PMMRC local coordinator workshop in March 2009 • Local assessment at time of classification of cause of death • Checked by national coordinator with feedback to local coordinator • National coordinator visits ~5 DHB meetings per year
Data Quality 2009 • Audit by national coordinator: – 68 randomly selected perinatal deaths – Potentially avoidable perinatal death • 19% by local assessment • 31% at audit – 2/48 from “no” to “yes” – 6/7 from “not stated” to “yes”
Findings: Perinatal related deaths 2009 Contributory factors Yes Perinatal related deaths n=720 n % 169 24 No Not stated 465 82 65 11 Potentially avoidable 98 14 5 th report PMMRC: Page 60
Findings: Perinatal related deaths 2009 Contributory factors Yes No Not stated Stillbirths n=401 n % 102 25 250 62 49 12 Potentially avoidable 60 15 Neonatal deaths n=182 n % 61 34 103 57 18 10 35 19 5 th report PMMRC: Page 60
Findings: Perinatal related deaths 2009 Perinatal related deaths n=720 Contributory factors n % Total 169 24 Organisational/management 34 5 Technology and equipment 6 1 Environment 12 2 Personnel 50 7 Barriers to access/engagement 111 15 5 th report PMMRC: Page 62
Findings: Perinatal related deaths 2009 5 th report PMMRC: Page 63
Absolute numbers of perinatal related deaths with contributory factors by PDC: 2009 5 th report PMMRC: Page 65
Conclusions • In 2009, a tool for assessing contributory factors and potential avoidability of perinatal death was introduced. • Utilises “local” review • The findings are preliminary as the process becomes familiar
Conclusions • Contributory factors were assessed as present in at least 24% of perinatal deaths, and 14% were potentially avoidable. • Most common factors were barriers to access and/or engagement with care (15%), personnel factors (7%) and organisational/management factors (5%)
International comparison data • South Australia 2008 (n=608) – “Independent audit” – 44% contributory factors – No assessment of rate of potentially avoidable death • Dutch perinatal audit project 2009 (n=228) – “Independent audit” – 32% contributory factors (Substandard care factors) – 9% potentially avoidable • Rotterdam 2008 (n=137) – Regional audit – 50% contributory factors – 26% possible and likely avoidable
Implications • Preliminary data • Possible issues with using the tool: need for ongoing local support and education • May result in an increase in rates of contributory factors and potential avoidability in next few years • Recommendations arising from the data
Future directions • Ongoing support and education in use of the tool • Plan to compare local to independent review of perinatal deaths in assessment of contributory factors and potential avoidability • Plan to use the tool for severe maternal morbidity review at Auckland Hospital • How do we use the data obtained to lead quality improvement in maternity care…
Acknowledgements • Local coordinators • National coordinator – Vicki Masson • PMMRC members
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