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Search results for "Discontinuities, Gaps, and Hand-Off Problems"
Journal Article > Study
Forster AJ, Fung I, Caughey S, et al. Obstet Gynecol. 2006;108:1073-1083.
This study used a trained observer to monitor obstetric patients for potential adverse events. Based on a predefined set of 72 triggers (eg, admission to intensive care unit, stat cesarean delivery, staff unavailability), the observer captured relevant information about the events, which were later analyzed by a multidisciplinary team. Investigators identified more than 100 triggers, and while very few serious adverse events were described, a number of potential adverse events raised questions about system problems. The authors advocate for use of their methodology to complement existing mechanisms in collecting information on adverse events.