A 37-year-old pregnant woman was admitted to the hospital for scheduled induction of labor for postterm dates. Early the next morning, intravenous oxytocin was administered to induce labor.
When the obstetrics team rounded on the patient several hours later, AROM (artificial rupture of membranes) was recommended to accelerate labor. The intern reviewed the patient’s chart and noted that a culture done from a vaginal and rectal swab at 36 weeks was negative for group B streptococcus (GBS)—a bacteria that sometimes colonizes the gastrointestinal and genital tracts of pregnant women. If documented at any time during pregnancy, the infant is at increased risk of infection at the time of delivery. The intern failed to note that faxed records from a clinic outside the hospital system included another culture—a urine culture positive for GBS. This test had been ordered at an office visit earlier in the patient’s pregnancy. Given this positive culture, to prevent transmission of GBS infection to the infant, the patient should have been started on intravenous antibiotic prophylaxis before the membranes were ruptured.
The senior resident on the team happened to review the faxed records and noted the positive urine culture. She immediately ordered antibiotics and delayed AROM for several hours to allow time for the medication to infuse. Luckily, the senior resident’s “catch” made this case a near miss, and the patient ultimately delivered a healthy infant and experienced no adverse consequences (Malana & Lyndon, n.d.)
A near miss happens when a medical error occurs but is caught before it reaches or harms the patient. When health care providers either do something wrong OR fail to do the right thing AND this leads to an unintended outcome or potential for unintended outcome, this is defined as a medical error. When an error occurs it can result in either a near miss or adverse event. In the example above, the error was the order and plan for AROM prior to antibiotic administration.
An adverse event is harm resulting from medical care and is defined by the Institute for Healthcare Improvement as “unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death” (Griffin & Resar, 2009). This includes what is identified by the National Quality Forum as never events or serious reportable events such as: surgery on the wrong patient, retained foreign objects (sponges/needles/instruments), falls associated with patient death or serious injury, and maternal or neonatal death or serious injury in a low risk pregnancy associated with labor or delivery (National Quality Forum, 2011). It’s important to note that not all adverse events occur from poor medical care. For example, the following scenarios would both qualify as an adverse event:
- The patient who is NOT assessed for drug allergies by healthcare providers, has a known drug allergy, subsequently receives this medication, and has a reaction
- The patient who is assessed for drug allergies, has never taken the drug, and then has a reaction.
Both occur as a result of medical care with one being due to a gap in the process and the other being nonpreventable. Hence adverse events are broken down into preventable and nonpreventable categories. Going back to the GBS example, if the newborn developed GBS infection as a result of the mother not receiving antibiotics and delaying AROM, then this would qualify as an adverse event because of the need for additional treatment and monitoring.
Griffin FA, Resar RK. IHI Global Trigger Tool for Measuring Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2009. (Available on www.IHI.org)
Malana, J. & Lyndon, A. Near Miss With Neonate. (n.d.). Retrieved from https://psnet.ahrq.gov/web-mm/near-miss-neonate
National Quality Forum (NQF), Serious Reportable Events In Healthcare—2011 Update: A Consensus Report, Washington, DC: NQF; 2011.
Wachter, R. M. (2007). Understanding patient safety. McGraw Hill.