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Root Cause Analysis (RCA) of a Maternal Death in Markazi Province: a Methodological Research in Clinical Epidemiology
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Ali Ahmadi   , Babak EShrati , Mehdi Nowrozi , Negin Moshtaghi , Leila Lashkari |
| Department of Epidemiology, Shahid Beheshti University of Medical Sciences |
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Abstract: (16022 Views) |
Background & Objectives: Different studies performed in the world and Iran reported the
educational level of the mother, history of more than four pregnancies, living
in rural areas, receiving no prenatal health care, and lack of access to
maternal emergency services as the most important factors affecting maternal
mortality rate. Few studies have determined contribution of indirect causes of
maternal deaths. This study aimed to determine the contribution of indirect
causes of a maternal death in Markazi province.
Methods: This is a retrospective and
descriptive-analytical study. Case report method and Root Cause Analysis (RCA),
as an important method used in clinical epidemiology, were applied to describe
and analyze a maternal mortality occurred in Markazi province, respectively.
This approach deals with identification and solving the root causes of health
problems (Sentinel Event). Data were collected by interview and inspection of
written documents. Bayesian analysis and calculation of the conditional
probabilities were applied using Netica 5.08 software.
Results: Receiving no maternal prenatal
care, not following the ministerial and provincial guidelines, lack of team
working and coordination between medical specialists in the treatment of
high-risk pregnant women in the hospital were identified as indirect causes of
the maternal death. Indirect causes accounted for 43% of the maternal death.
Conclusion: Indicating cardiomyopathy as a cause of death on death
certificate of the mother was incorrect. Determining the principal cause of the
death, Root Cause Analysis, and eliminating the indirect causes of the death
play important roles on decreasing 50% of the maternal deaths. |
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| Keywords: Maternal Death, Root Cause Analysis, Indirect Cause of Death, Clinical Epidemiology, Clinical Governance |
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Full-Text [PDF 272 kb]
(5968 Downloads)
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Type of Study: Research |
Subject:
Special
Received: 2014/01/21 | Accepted: 2014/01/21 | Published: 2014/01/21
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