Types of AEs, near-misses and their consequences

Strategies to promote interventions to improve PS

Domains related to the WHO’s Patient Safety Competence Outcomes

HCPs: Psychosocial and physical attribution of blame and responsibility [23] [24] ;

Managing risks [26] ;

Near-misses and AEs are judged in terms of events and on how others react to them [28] ;

Failure to recognize and respond to unexpected changes in a woman’s condition during labour [30] ;

Failure to learn lessons [30]

Safety culture [22] [26] [30] and policy development [23] ;

Leading and supporting staff [26] ;

Promoting reporting and being open when things go wrong [26] [28] [30] ;

Learning and sharing safety lessons [26] [28] [30]

Contribute to patient safety culture by increased reporting of AEs and near-misses

HCPs: Inadequate communication between HCP’s in the healthcare system (community and in-hospital) [24] [27] and with the patient [29]

Feedback and acknowledgement [30] ;

Team training, high-risk clinical drills, use of professional guidelines and standard documentation [24] [28] -[30] ;

Task description and delineation [29]

Communicate effectively;

Teamwork and collaboration

HCPs: Ethical conflicts due to misunderstanding [30]

Safety climate, the possibility to talk about failure [24] ;

Helping to prevent mistakes [28] ;

Prioritization of safety [30]

Identify failure modes;

Identify maternal near-miss

HCPs: Inadequate infrastructure [22] ;

Referral procedures, risk assessment by telephone triage and technical procedures [29]

Support incident management activities and leadership capacity [22]

Optimize environmental resources to ensure PS

PH: Loss of trust and responsibility for their own safety [23] [24]

Involving and communicating with patients and the public [26] ; Involving patients in their own care and treatment [26] ;

Use of clinical decision support [25] [30]

Optimize patient-centred care

PH: Wrong obstetric medication resulting in harmful errors [25] ;

Medication procedures [29]

Medication administration that enables interdisciplinary quality improvement [25] [28]

Manage safety risks

Leadership

PH: Perinatal cases of patients’ complaints [29]

Clinical management [29]

Manage safety risks