RESUMO
OBJECTIVE: To describe the design and implementation of a Quality Incident Notification (QIN) system in an obstetrical unit and provide an analysis of the frequency and nature of events captured by the system. METHODS: We implemented a system to capture quality events, consisting of an on-line form that was easily accessible to all levels of staff. A list of quality indicators was developed to indicate potential safety concerns, near misses, or poor outcomes that required closer scrutiny. We retrospectively analyzed the cases reported in the first year following introduction of the QIN for the presence, severity, and avoidability of harm. RESULTS: During the 12-month study period there were 6752 deliveries, and 578 QINs were generated, a rate of one QIN for every 11.7 deliveries (8.5%). The most frequent indicators reported were "neonatal near miss" (15.4%), "records/results" (14.5%), and "staff communication" (10.0%). Out of the 497 QINs with complete data, 67 (13.4%) showed minor harm to the mother, the baby, or both, and 37 (7.4%) QINs showed major harm. Only 28 of the 110 cases of actual harm were considered to be caused by the medical care (0.4% of all deliveries), and 14 patients were judged to have experienced avoidable actual harm due to medical care (0.2% of all deliveries). CONCLUSION: The QIN system captured a relatively low rate of adverse events, with about half of these being avoidable. Used consistently, this type of system can be an effective tool for risk management and improvement of practices.
