AFJOG

ORIGINAL RESEARCH to systematically report and analyse critical incidents. 10 However, only recently has there been an increased focus on critical incidents in gynaecology. Thus, there is limited published literature on the topic of critical incidents in gynaecology compared to obstetrics practice. 11 Current literature on gynaecological morbidity studies includes adverse event reporting, amongst other systems. 2 In healthcare, adverse incidents refer to unintended consequences resulting in temporary or permanent disability, death or prolonged hospital stay. 8 Although the incidence of adverse events is higher in surgical compared to medical specialities, there is a paucity of data exploring adverse events and their consequences in Gynaecology. 11-13 Lack of dedicated or underdeveloped auditing is a probable causative factor in some areas. 5 A systematic review and meta-analysis by Tanaka et al. 2 on the incidence of adverse events, preventability and mortality in gynaecological hospital admissions reported that approximately one in ten gynaecological in-patients suffer at least one adverse event, half of which are preventable. 2 In addition, the incidence of adverse events in gynaecological hospital admissions was 11%, of which 53%was preventable, and the mortality rate was 1%. 2 It has been shown that the public’s confidence in doctors and hospitals has been negatively affected in recent years as a result of critical incidents. 14 Evidence suggests that increased transparency and honest communication with patients after adverse incidents can improve provider-patient relationships. 9,15 To restore and retain the lost confidence, healthcare systems and strategists need to show that effective mechanisms exist to assess and manage critical incidents. 6 A recent review was conducted to summarise the knowledge of healthcare professionals in handling the aftermath of critical incidents and to develop recommendations to reduce their negative impact on patients, their relatives and health professionals. 16 The following recommendations were made to improve the recognition and communication of critical incidents to patients and relatives: (i) drafting clear safety and organisational policies, (ii) adopting a proactive approach to prevent the reoccurrence of critical incidents, (iii) ensuring availability of resources to provide an appropriate response, (iv) thorough analysis of the critical incidents and (v) informing patients and/or family members of critical incidences early. 16 Globally, studies show that a significant proportion of adverse events are preventable. 8 The Harvard Medical Practice study reported the incidence of adverse events and negligence in hospitalised patients in 51 hospitals in NewYork and found that 4% of adverse events occurred in hospitalised patients. 17 It was further revealed that 28% of the adverse events were due to negligence, while 14% led to death. 18 In addition, an Australian retrospective study of patient records in 28 hospitals in New South Wales reported an adverse event rate of 17%, and about 56% of those adverse events were preventable. 19 Since July 2010, the Canadian Hospital Board (as per Regulation 965 of the Public Hospitals Act) has been required to establish a system of analysing critical incidents and develop a systematic plan to reduce or avoid the risk of repeat or similar critical incidents. 7 Monitoring adverse events is important as they can have significant economic impacts on individuals, healthcare providers, and the wider healthcare system. Adverse events may increase healthcare costs due to the need for additional medical treatment, hospitalisation, and rehabilitation services. 20 Patients may require extended hospital stays or additional surgeries, which can significantly increase healthcare costs. Adverse events can also result in lawsuits, which can be costly for healthcare providers and facilities in terms of significant financial settlements, legal fees, and increased malpractice insurance premiums. 14,21 Adverse events can result in lost productivity for patients and healthcare providers. This is because patients may require time off work to recover from medical errors or hospital- acquired infections, while healthcare providers may need to take time off to deal with the aftermath of adverse incidents. 15 Low- and middle-income country perspective A study conducted in eight African and Middle east countries in Africa has found an average adverse events rate of 8% across these eight countries. 22 This finding is similar to other studies, with a rate of about 10%. 17, 23 However, the proportion of preventable adverse events was significantly high at 83%. 22 A Kenyan study conducted at a tertiary hospital found that reviewing medical records was more effective than incident reporting (1.4% vs 0.03%) in identifying adverse events, indicating that many incidents are never reported. 24 Arguably, this may result from fear of being held responsible for the occurrence of the adverse event. 9 It could also be due to inadequate staff education on the importance of reporting an adverse event. 25 South African scenario A set of gynaecological critical incident criteria, which includes adverse events, have been defined and developed by Pattinson and Lombaard. 3 According to the definition, “a critical incident is defined as any cause or action that leads to extra morbidity in the patient as well as any intervention that when it is performed could lead to serious morbidity or mortality in the gynaecological wards”. 3 In accordance with this criterion, a woman may suffer from an adverse event and a critical incident. The authors published a study entitled, “Gynaecological critical incidents: An audit of current gynaecological practice at Kalafong Hospital over a six-month period”, which found that the hospital had a critical incident rate of 8%, with the majority related to elective admissions compared to the emergency admission group. A study on the adverse incidents in Gynaecology at King Edward VIII Hospital, Durban, South Africa, reported an adverse event incidence of 12% of admissions, where 52% were avoidable. 1 The most common type of adverse event was therapeutic mishaps, especially failure to initiate treatment on time. Visceral injuries, bladder injuries, in particular, were the second most common type of critical incidents (3% of major gynaecological surgery). The criteria set by Pattinson and Lombaard are important in setting up a system to analyse and potentially minimise recurrences of critical events. The use of these criteria to study gynaecological morbidity is more accurate and inclusive and may enable us to differentiate between clinical incidents and infrastructural or organisational factors. Research on critical incidents can stimulate data- driven decision-making and planning between healthcare providers, politicians, and governmental/non-governmental organisational structures. Critical incidents/incidents form the basis of societies’ mistrust of healthcare providers and institutions. 20 To this end, the healthcare system needs to show that effective mechanisms exist for assessing, documenting and managing critical incidents. African Journal of Obstetrics and Gynaecology | Volume 1 | Issue 1 | 2023 | 16