Information gaps in newborn care and their potential for harm.

ABSTRACT

BACKGROUND: Access to complete and correct patient information is vital for physicians to make appropriate patient care decisions and to avoid medical errors. However, the perinatal period represents a unique situation in which care of the fetus is initiated by an obstetrician and then assumed by either a pediatrician or a family practice physician after birth. This often abrupt handoff of care has the potential to result in an inadequate transfer of information and significant gaps in care. A study was conducted to determine the presence and extent of information gaps in newborn care. METHODS: Maternal demographics and history, and results of all prenatal laboratory tests, were obtained from maternal interviews and medical records. The collected data were compared with information in infant medical records. A positive maternal history not documented in the infant medical record was counted as an information gap. RESULTS: Of 72 enrolled mother-infant dyads, nearly all (71 [99%]) of mothers had at least one positive history in the areas reviewed, and 59 (82%) newborn charts had one or more information gaps. Thirty-eight (53%) newborn charts had one of two or fewer information gaps, and 17 (24%) had four or more information gaps. None of the infants with a maternal history of depression, positive family history of an infectious disease, potentially inheritable genetic disorder, or family history of phototherapy or exchange transfusion had these documented in their medical records. CONCLUSIONS: The results of this study suggest that significant information gaps are common in newborn care at birth and may have the potential for an adverse impact on the care and outcomes of the newborn. Obtaining a history directly from the parents rather than relying on maternal medical records may minimize or eliminate these information gaps and thus improve newborn care.