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A QI Driven Approach to the issue.
 
Waring, JJ. A qualitative study of the intra-hospital variations in incident reporting. International Journal for Quality in Health Care 16: 347-352.

Objective. To determine the relationship between variations in hospital incident reporting and the corresponding attitudes and
participation of medical professionals.
Methods. An in-depth qualitative case study using semi-structured interviews with hospital managers and clinicians. Twelve
participants were theoretically sampled based on their involvement with clinical risk management and patient safety. Twentyfive
medical physicians and four risk leads were selected from the specialist hospital departments of Obstetrics, Anaesthesia,
General Surgery, Acute Medicine, and Rehabilitation. The data were analysed to develop a descriptive account of the intrahospital
variations in reporting and the associated attitudes of physicians.
Setting. The research was conducted in a single acute National Health Service Hospital Trust in the English Midlands.
Results. The qualitative data revealed significant variations in the intra-hospital organization of incident reporting between
medical specialities that corresponded with the attitudes and participation of medical staff. Specifically, it was found that medical
doctors were more inclined to report incidents where the process of reporting was localized and integrated within medical
rather than managerial systems of quality improvement. Underlying these variations, it is suggested that medical reporting is
more likely when physicians have greater control or ownership of incident reporting, as this fosters confidence in the purpose
of reporting, in particular its capacity to make meaningful service improvements whilst maintaining a sense of collegiality and
professionalism.

 
Mayberry LJ. A Quality of Health Outcomes Model for guiding obstetrical practice . J Nurs Scholarsh 33: 141-6.

PURPOSE: To describe the application of the Quality of Health Outcomes Model, introduced by the American Academy of Nursing Expert Panel on Quality of Health Care, to obstetrical care, particularly second-stage labor. ORGANIZING FRAMEWORK: The model is different from the more linear structure-process-outcome frameworks used in the past to a dynamic conceptualization of reciprocal relationships among the system, intervention, client, and outcome components. Analysis of these components can provide a comprehensive picture of the complexity of patient care decision making in hospital labor and delivery units. CONCLUSIONS: Research findings indicate that interventions such as cesarean delivery and epidural analgesia may result in several significant quality of health outcomes for women that should receive increased attention. Uses of this model for shaping best practices among physicians and nurses and for setting directions for priorities in future interdisciplinary research and health policy are discussed.

 
Coetzee EJ, Dommise J, Anthony J. A randomised controlled trial of intravenous magnesium sulphate versus placebo in the management of women with severe pre-eclampsia. British Journal of Obstetrics and Gynaecology 105: 300-303.
 
Oboro VO, Tabowei TO. A randomised controlled trial of misoprostol versus oxytocin in the active management of the third stage of labour. J Obstet Gynaecol 2003; 23: 13-6.

Our objective was to compare oral misoprostol with intramuscular oxytocin in the prevention of postpartum haemorrhage. Four hundred and ninety-six women were randomised to receive either 600 microg misoprostol orally or 10 IU oxytocin intramuscularly after delivery. There were no significant differences between the misoprostol and oxytocin groups with regard to the incidence of postpartum haemorrhage (1% vs. 0% respectively, relative risk (RR) 3.02, 95% confidence interval (CI) 0.32-28.88) or drop in haemoglobin concentration (0.71 g/dl vs. 0.68 g/dl, respectively, P = 0.699). The length of the third stage of labour and the percentage of women requiring manual removal of placenta, further oxytocics or blood transfusion were also similar. Shivering was significantly higher with misoprostol (57% vs. 14%; RR 4.06, CI 2.93-5.62), but there were no differences in other side effects. We conclude that oral misoprostol can replace intramuscular oxytocin in reducing postpartum haemorrhage in low-risk women, in developing countries, especially as it is administered orally and it is thermostable in tropical conditions.

 
van Runnard Heimel PJ, Huisjes AJM, Franx A, Koopman C, Bots ML, Bruinse HW. A randomised placebo-controlled trial of prolonged prednisolone administration to patients with HELLP syndrome remote from term. European Journal of Obstetrics & Gynecology 187-193.

Objectives: To evaluate the effect of prolonged administration of high-dose prednisolone on early onset HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome during expectant management.
Study design: A randomized, double-blind trial was performed in 31 pregnant women with HELLP syndrome with an onset before 30 weeks gestation. Patients received either 50 mg prednisolone or placebo intravenously twice a day. Primary outcome measures were the entry-to-delivery interval and the number of recurrent HELLP exacerbations in the antepartum period.
Results: Serious maternal morbidity was considerable, in particular in the placebo group where even on maternal occurred as a consequence of liver rupture. The mean entry-delivery interval did not differ between the prednisolone group (6.9 days) and the placebo group (8.0 days). However, patients in the prednisolone group had a significant lower risk of a recurrent HELLP exacerbation after the initial crisis had subsided, as compared to patients in the placebo group (HR 0.3, with 95% CI 0.3–0.9). Platelet count recovered faster in the prednisolone group as compared to the placebo group (mean 1.7 days versus 6.2 days, P Conclusions: HELLP syndrome remote from term causes high risk for serious maternal morbidity and mortality. When expectant management is pursued in selected patients with a HELLP syndrome remote from term, prolonged administration of prednisolone reduces the risk of recurrent HELLP syndrome exacerbations.

 
Orji E, Agwu F, Loto O, Olaleye O. A randomized comparative study of prophylactic oxytocin versus ergometrine in the third stage of labor. Int J Gynaecol Obstet May 2008; 101: 129-32.

OBJECTIVE: To compare the effect of prophylactic use of oxytocin and ergometrine in management of the third stage of labor. METHODS: A prospective randomized study of 600 women assigned to receive either oxytocin or ergometrine in the third stage of labor. Outcome measures were the predelivery and 48-hour postdelivery hematocrit, duration of the third stage, specific side effects, and incidence of postpartum hemorrhage. Statistical analyses were done using the t test for continuous variables and chi(2) test for categorical variables. The level of significance was set at P

 
Rouse, DJ, Hirtz, DB, Thorn, E, Varner, MW, et. al. A Randomized, Controlled Trial of Magnesium Sulfate for the Prevention of Cerebral Palsy. NEJM Thu, 08/28/2008; 359: 895-905.

BACKGROUND
Research suggests that fetal exposure to magnesium sulfate before preterm birth
might reduce the risk of cerebral palsy.
METHODS
In this multicenter, placebo-controlled, double-blind trial, we randomly assigned
women at imminent risk for delivery between 24 and 31 weeks of gestation to receive
magnesium sulfate, administered intravenously as a 6-g bolus followed by a
constant infusion of 2 g per hour, or matching placebo. The primary outcome was
the composite of stillbirth or infant death by 1 year of corrected age or moderate or
severe cerebral palsy at or beyond 2 years of corrected age.
RESULTS
A total of 2241 women underwent randomization. The baseline characteristics were
similar in the two groups. Follow-up was achieved for 95.6% of the children. The rate
of the primary outcome was not significantly different in the magnesium sulfate
group and the placebo group (11.3% and 11.7%, respectively; relative risk, 0.97; 95%
confidence interval [CI], 0.77 to 1.23). However, in a prespecified secondary analysis,
moderate or severe cerebral palsy occurred significantly less frequently in the
magnesium sulfate group (1.9% vs. 3.5%; relative risk, 0.55; 95% CI, 0.32 to 0.95).
The risk of death did not differ significantly between the groups (9.5% vs. 8.5%;
relative risk, 1.12; 95% CI, 0.85 to 1.47). No woman had a life-threatening event.
CONCLUSIONS
Fetal exposure to magnesium sulfate before anticipated early preterm delivery did
not reduce the combined risk of moderate or severe cerebral palsy or death, although
the rate of cerebral palsy was reduced among survivors. (ClinicalTrials.gov number,
NCT00014989.)

 
Geller SE, Rosenberg D, Cox S, Brown M, Simonson L, and Kilpatrick S. A scoring system identified near-miss maternal morbidity during pregnancy. J Clin Epid 2004; 57: 716–720.

OBJECTIVE: The objective of this study was to develop a scoring system for identifying women with near-miss maternal morbidity, and differentiating these women from those with severe but not life-threatening conditions. STUDY DESIGN AND SETTING: The study was conducted at the University of Illinois Medical Center at Chicago (UIMC), which is a tertiary care hospital with approximately 2,220 births per year. UIMC is in a major urban area serving a predominantly African-American and Latina population. This article focuses on five clinical factors: organ failure (>/=1 system), extended intubation (>12 hr), ICU admission, surgical intervention, and transfusion (>3 units), grouped into several scoring system alternatives. The total score on each scoring system was calculated as the weighted sum of the clinical factors present for each woman. RESULTS: The five-factor scoring system had the highest specificity (93.9%), but the four-factor scoring system, which eliminated organ system failure for simplification of data collection, still had a specificity of 78.1%. CONCLUSION: Near-miss morbidities identified using the scoring systems presented can be incorporated into clinical case review and epidemiologic studies to enhance the monitoring of obstetric care and to improve estimates of the incidence of life-threatening complications in pregnancy.

 
Blatt R, Christianson MK, Sutcliff KM, Rosenthal MM. A sensemaking lens on reliability. Journal of Organizational Behaviour 27: 897-917.

This study assessed the applicability of current theories of reliability in dynamic settings by exploring the sensemaking processes experienced by a sample of medical residents around lapses in reliability of patient care. Important differences in lapses surfaced, particularly with respect to whether actors were aware that a lapse was occurring in real-time and whether there was anything they could do or say to mitigate or prevent the lapse. In over half of the incidents recounted, the actors did not become aware of the lapse in reliability until after the consequence of the lapse had occurred or the consequence occurred simultaneously with the recognition of the lapse. In other incidents, they faced a critical moment in which they had to decide whether and how to act to intervene in real-time. In the majority of these critical moments, residents had an issue of concern to voice that could have helped mitigate or correct
the lapse but instead they remained silent. Issues related to identity and relationships appeared to either inhibit or promote voice during critical moments. We end with ideas for how our findings can inform existing work on reliability in healthcare and the growing literature on voice and silence in organizations.