Care management problems on the labour ward: 5 years' experience of clinical risk management

J Obstet Gynaecol. 2002 Sep;22(5):470-6. doi: 10.1080/0144361021000003564.


This is a retrospective review of 310 reports by staff following clinical risk incidents on the labour ward between 1996 and 2000 in a district general hospital with 3600 deliveries per year. Care management problems were identified and Reason's model of critical incident analysis applied to classify them into person- and system-based problems. Care management problems occurred in 165 (53%) cases, representing 0.9% of all deliveries. The main person-based problems were errors in CTG interpretation (22%), poor operative technique (22%) and non-standard practice/poor clinical judgement (19%). System-based problems included insufficient staff numbers (45%), ineffective teamwork/communication (39%) and inadequately maintained equipment (7%). Structured analysis of clinical incident reports can identify the extent and nature of obstetric care management problems and highlight important contributory areas potentially amenable to improvement.

MeSH terms

  • Case Management / standards*
  • Case Management / statistics & numerical data
  • Delivery Rooms / standards*
  • Delivery Rooms / statistics & numerical data
  • Delivery, Obstetric / standards
  • Delivery, Obstetric / statistics & numerical data
  • Female
  • Hospitals, District
  • Hospitals, General
  • Humans
  • Infant, Newborn
  • Medical Errors / statistics & numerical data*
  • Pregnancy
  • Retrospective Studies
  • Risk Management / statistics & numerical data*