Back to Annual Meeting Page		American Public Health Association 133rd Annual Meeting & Exposition December 10-14, 2005 Philadelphia, PA

Abstract #104485

Suzanne M. Cox, MPH¹, Stacie Geller, PhD², and Sarah J. Kilpatrick, MD, PhD². (1) Community Health Sciences, School of Public Health, University of Illinois at Chicago, 1603 W. Taylor Street, SPH-PI, Chicago, IL 60612, 215-732-1293, scox3@uic.edu, (2) Department of Obstetrics and Gynecology (MC 808), University of Illinois, College of Medicine, 820 S. Wood Street, Chicago, IL 60612

Purpose: An evidence-based model of preventability in maternal morbidity and mortality is presented.

Methods: Maternal morbidities and mortalities (n=237) were identified at the University of Illinois at Chicago Medical Center and its 10 perinatal network hospitals. A team of clinicians reviewed medical records and classified each death or morbidity as preventable or not preventable. Details as discussed by the clinicians were recorded and entered into a Microsoft Access database in text fields. In qualitative analysis, themes (such as “failure to order labs”) were summarized from the text fields. Themes were organized by headings with temporal and contextual relevance. Frequencies of types of preventable events were calculated.

Results: Of 237 women, there were 79 preventable events attributable to providers and systems. The analysis produced a descriptive model with the 10 broad chronological/context headings, each of which had multiple themes. Provider-related issues included assessment/point of entry, diagnosis/recognition of high-risk status, referral to expert, treatment, management hierarchy, education, and discharge. System-related issues included communication, policies/procedures, and documentation. In this study, the most common types of preventable events were diagnosis/recognition of high-risk (54.4%), treatment (38.0%), and documentation (30.4%).

Conclusions: A descriptive model of preventability is illustrated that can be used by departments and hospitals to categorize preventable events in maternal morbidity and mortality. This theoretical model can be incorporated into quality assurance, clinical case review, and epidemiologic studies to enhance the monitoring of hospital-based obstetric care and to improve estimates of preventable cases.

Learning Objectives: At the conclusion of the session, the participant in this session will be able to

• List the main causes of provider and system related preventability of maternal morbidity and mortality.
• Apply the described preventability model to their own healthcare setting.
• Identify and categorize preventable events within the healthcare delivery environment that lead to excess morbidity and mortality.

Presenting author's disclosure statement:

I wish to disclose that I have NO financial interests or other relationship with the manufactures of commercial products, suppliers of commercial services or commercial supporters.

Recorded presentation