Table 3.
Summary of contributing factors to adverse events or medical (near)misses and maternal deaths. This table describes, per quality-of-care mechanism, the contributing factors described per study. Percentages reflect the relative number of cases (from this study) in which this factor contributed to an adverse event.
| Quality of Care Mechanism | Study | Results | Percentages |
|---|---|---|---|
| Patients | Iwuh [22] | Patient education (lack of information) | 6.25 |
| Clinical practice | Aikpitanyi [14] | Delay in commencing treatment | 27.8 |
| Benimana [15] | Diagnostic delays | 41.3 | |
| Therapeutic delays | 5.8 | ||
| Florea [18] | Protocol | 5.9 | |
| Nursing resources | 0.2 | ||
| Physician resources | 1.7 | ||
| Other personnel | 0.7 | ||
| Equipment/resources | 6.9 | ||
| Records/results | 14.5 | ||
| Staff communication | 10.0 | ||
| Patient/family communication | 1.6 | ||
| Delay | 1.0 | ||
| Haddad [20] | Lack of trained staff | 5.1 | |
| Difficulty in monitoring | 8.1 | ||
| Delay in diagnosis | 5.6 | ||
| Delay in starting treatment | 6.5 | ||
| Delay in referral/transfer of the case | 5.2 | ||
| Improper management of the case | 21.8 | ||
| Iwuh [22] | Not managed at the level of care that was needed | 20.5 | |
| Clinical assessment (diagnosis), Problem recognition | 4.5 | ||
| Delay in referring | 0.9 | ||
| Managed at inappropriate level | 0.9 | ||
| Monitoring problems | 13.4 | ||
| Johansen [24] | Failure in surveillance | 36 | |
| Failure in diagnostics | 17 | ||
| Failure in operative delivery | 8 | ||
| Failure in resuscitation | 2 | ||
| Sayinzoga [35] | Lack of skilled staff | ||
| Insufficient diagnostic means | |||
| Inadequate monitoring of labour (use of partograph) | |||
| Delay in recognising the complication or administering the correct treatment | |||
| Insufficient follow-up in post-operative or postpartum period | |||
| No respect for asepsis | |||
| Not following protocol | |||
| Inadequate resuscitation | |||
| Insufficient follow-up of anaesthesia induction | |||
| Insufficient pre-operative preparation | |||
| Poor quality of antenatal care visit | |||
| Sorensen [36] | Training of staff insufficient | ||
| Habte [19] | Poor birth preparedness and poor complication readiness | 85.2 | |
| Johansen [25] | Delay in decision to operate | 8 | |
| Delay in decision to delivery time | 20 | ||
| Failure monitoring/Misinterpretation CTG | 13 | ||
| Medication error | 56.2 | ||
| Nasorro [32] | Delay in managing uterine atony | 17 | |
| Carvalho [16] | Inadequate prenatal care: improper conduct with patient | 5 neonatal near-miss/1 death | |
| Huner [21] | Peripartum therapeutic delay | 44.32 | |
| Diagnostic error | 36.36 | ||
| Inadequate birth position | 34.09 | ||
| Medication error | 2.27 | ||
| Zewde [38] | Insuffiency of medical staff | ||
| Delay in making diagnosis | |||
| Poor communication during referral | |||
| Emergency medicine | Aikpitanyi [14] | Delay in deciding to refer patients | 5.6 |
| Haddad [20] | Difficulty in communication between hospital and regulatory centre | 18.8 | |
| Delay in referral/transfer | 5.2 | ||
| Mahmood [29] | Failure in delay and emergency response | 42.9 | |
| Delay in procedures | 28.6 | ||
| Lack of policy, protocol and guidelines. | 46.4 | ||
| Delay in emergency response | 33.3 | ||
| Lacking knowledge and skills | 60 | ||
| Failure to follow best practice | 70 | ||
| Lack of recognition of seriousness. | 50 | ||
| Sayinzoga [35] | delay of the ambulance to reach the health centre | ||
| Nasorro [32] | Inadequate preparation in complete readiness | 17 | |
| Management | Aikpitanyi [14] | Lack of skilled manpower | 11.1 |
| Mahmood [29] | Inadequate access to senior clinical staff | 39.3 | |
| Failure to seek supervision or help | 43.3 | ||
| Sayinzoga [35] | Delay in referring the patient at high level | ||
| Sorensen [36] | Staff not available | ||
| Nasorro [32] | Delated referral from another facility | 26 | |
| Saucedo [34] | Lack of 24/7 on-site presence of obstetrician or anesthesiologist | 5/66 28/81 obstetrician | |
| 13/66 37/81 anesthesiologist | |||
| Zewde [38] | Unavailability of a senior obstetrician | ||
| Inappropriate management | |||
| Multiple referrals between health facilities | |||
| Health workforce | Johansen [24] | Failure in teamwork | 14 |
| Johansen [25] | Failure in cooperation between midwife and physician | 16 | |
| Pharmaceuticals and medical products | Aibar [13] | Peripheral venous catheter | 86.2 |
| Closed bladder catheter | 18.9 | ||
| Aikpitanyi [14] | Non-availability of blood products | 33.3 | |
| Lack of essential emergency drugs | 11.1 | ||
| Benimana [15] | Delayed or lacking supplies (blood and medication) | 5.8 | |
| Haddad [20] | Lack of medication | 1.8 | |
| Absence of blood products | 1.3 | ||
| Johansen [24] | Failure in administration of medication | 11.1 | |
| Sayinzoga [35] | Lack of isogroup blood | ||
| Wasim [37] | Inadequacy in blood arrangement | ||
| Zewde [38] | Lack of supplies and equipment | ||
| Health Facilities | Aikpitanyi [14] | Non-functional ICU | 11.1 |
| Carvalho [16] | Inadequate prenatal care: difficult access due to lack of specialised services | 46.5 | |
| Mulongo [31] | Lack of continuity of care and coordination | ||
| Wasim [37] | Inadequacy in overburdened ICU | ||
| Information Systems | Iwuh [22] | Incomplete registration (lack of information) | 6.3 |
| Johanssen [24] | Failure in documentation | 5 | |
| Huner [21] | Lack of documentation |