AFJOG

ORIGINAL RESEARCH which was unsurprising as the patients' profiles were largely similar. The results from this study are slightly less than the WHO data, which estimates that about 10% of patients are affected by critical incidents. 4 It was reassuring to note that our results are comparable to reports from two South African studies focussing primarily on gynaecological patients. A study at Kalafong Provincial Tertiary Hospital by Lombaard et al. 3 reported a critical incident rate of about 8%, similar to the 7% we reported. 3 A study at King Edward Hospital VIII in KwaZulu-Natal province in 2005 found an adverse incident rate of 11%. 1 Characteristics associated with critical incidents The patients who suffered critical incidents had a median age of 42 (34 – 54) years. From published data, increasing age is a known risk factor for critical incidents. 2-3 A study by Wilson and colleagues in developing countries demonstrated a dose-response relationship between age and incidence of critical incidents. 22 They suggested that the observed association existed as increasing age is associated with fragility. Many patients who experienced critical incidents were gynae-oncology patients, which could be related to the fact that they are chronically unwell and more likely to have repeated admissions. It is, however, important to note that most of these patients were admitted for elective surgical treatment. The prevalence of HIV in this study sample was fairly high at 37%. This was higher than the commonly cited 25% prevalence among the general population of women (aged 15 – 64) in South Africa. 26 It is still even higher than the commonly cited 30% prevalence among sexually active and pregnant women attending antenatal care, who are at a much higher risk of HIV acquisition. 26-27 The results show that most (60%) deceased patients were HIV-positive. Therefore, the observed high HIV prevalence rate could explain the higher predominance of deaths as a cause of critical incidents obtained in this study. Spectrum of critical incidents The most (45%) prevalent type of critical incident was “omission of procedure” (n = 107), and it was predominantly the cancellation of surgical operations for various reasons. For example, a total of 49 operations were cancelled due to lack of theatre time, while other reasons for cancellation were lack of ICU/HCA beds, blood shortages, and poor patient pre-operative preparation. This type of critical incident is frequently associated with high morbidities, such as psychological stress among patients, which may result from financial losses because of additional hospital stays, medical expenses, and a loss of income. 17,19 It is also plausible that such incidents lead to patients losing confidence and dissatisfaction with the public health sector. 6,14 Death was the second most prevalent critical incident after procedure omission. A total of 66 deaths were recorded over the 3225 admissions giving an overall mortality rate of 2.2%. This is comparable to what is published in the literature. Most of the deceased were oncology patients, with cervical cancer being the leading cause of oncology deaths. The two South African studies into critical gynaecological incidents showed a mortality of 2.1% of all admissions 1 and 2.2% of all admissions.3 The finding of this study is also consistent with the low mortality rate among gynaecological hospital admissions of 1.2% (95% CI, 0 – 2.5% ) reported in a previous meta-analysis. 2 It is critical to note that unplanned surgical procedures were the third largest contributor towards critical incidents. The fact that most of these were due to emergency hysterectomies emphasises the need to ensure that frontline emergency healthcare workers in gynaecological departments, such as medical officers and registrars, are taught and proficient in conducting this procedure. Our data also shows that iatrogenic bowel and bladder injury was the next predominant cause of unplanned surgery as they contributed 3% (n = 6) of the unplanned operations, thus accounting for about 3% of the critical incidents. The reasons for the occurrence of these iatrogenic bladder and bowel injuries could not be ascertained from this study. Previously published data show that inexperienced surgeons have a higher rate of complications when compared to highly experienced surgeons. 28-29 Therefore, future studies can be conducted to confirm if junior or inexperienced surgeons show a higher rate of iatrogenic injuries than experienced surgeons in our setting. 30 Avoidable factors The data in this study show that one hundred and six (106) of the critical incidents were potentially avoidable factors. The most common avoidable factors were in the category of administrative factors (70%). In this category, lack of theatre time was the most common determinant and accounted for almost half of the avoidable factors, followed by lack of blood products, high care or ICU beds, and inadequate patient preparation for the surgical procedure. The WHO estimates that up to 50% of critical incidents are avoidable. 4 It is important to highlight that these administrative factors can be prevented by simple measures such as ensuring that the number of cases booked on the theatre slate can be completed in the allocated theatre time, thus minimising cancellations due to lack of theatre time. 31 A South African study on improving the efficiency of using theatre made recommendations which include: standardised booking forms with time allocations per case and predicted operating times to aid in appropriate scheduling of cases; clearly defined first-case start times that must be communicated to all theatre users and improved communication between senior anaesthetists and surgeons to scrutinise potentially early-terminating lists, and plan for adding an additional case to the list. 32 Next, proper planning, including arranging for a cell saver and securing blood products and high-care or ICU beds well in advance of the operation, will go a long way in minimising cancellations. It is equally important to ensure that the patients have a thorough diagnostic examination, have all the required results in the file and are also counselled and educated on the procedures and expectations, such as to keep nil per os for at least 6 hours before the operation. 31 Since patient-related factors were the next prevalent category for avoidable factors, several strategies can be implemented to minimise them. In this study, it is plausible that simple measures such as improved patient education to seek care early could significantly reduce the proportion of adverse incidents due to patient factors. 10, 33 Similarly, healthcare factors which might make women hesitate to seek care, such as long queues and bad staff attitudes, need to be addressed to minimise patient factors. 34 In this study, 8% of the avoidable factors were in the medical care category. Medical care-related adverse incidents could also be reduced by improving the knowledge of the African Journal of Obstetrics and Gynaecology | Volume 1 | Issue 1 | 2023 | 20