14 / 23
Page 51
Notes:
allied
academies
February 28-March 01, 2019 | Paris, France
Palliative Care, Obstetrics and Gynecology
Stroke and Clinical Trials
International Conference on
Joint Event on
International Conference on
&
Journal of Research and Reports in Gynecology and Obstetrics | Volume: 3
Human factors: The dirty dozen in CTG misinterpretation
Caroline Everden
Kingston Hospital NHS Foundation Trust, UK
T
he contribution of human factors to errors and adverse
outcomes within most healthcare systems cannot be
underestimated. In Obstetrics we rely on the cardiotocograph
as a non-invasive tool for detecting fetal hypoxia. However,
since its introduction in 1960 the CTG has failed to reduce the
rate of hypoxia-induced perinatal morbidity and mortality.
The recent Each Baby Counts report indicates that 62% of
stillbirths, neonatal deaths, and brain injuries of term babies
in labor in 2015 were related to errors in CTG interpretation
and management. This carries a significant financial burden
as recent figures from the National Health Service Litigation
Authority (NHSLA) show that Obstetrics makes up 50% of
the total value of negligence claims in the UK. The aim of this
review is to explore the different aspects of human factors and
how each contributes to CTG misinterpretation. We will be
using a framework devised by Gordon DuPont called the Dirty
Dozen. These are the 12 most common causes of error within
aviation maintenance: Lack of communication, complacency,
lack of knowledge, distraction, lack of teamwork, fatigue, lack
of resources, pressure, lack of assertiveness, stress, lack of
awareness, norms. We will discuss each of these and apply
them to common CTG misinterpretation themes. Obstetrics
is a highly pressured and often unpredictable specialty and,
because of these human factors and the working environment,
CTG interpretation errors occur. We believe that the solution
to reducing errors is 2-fold; a) increasing use of Human Factors
sciences and b) Improving understanding of the fetal physiology
that underpins CTG appearances.
Abbreviations: CTG: Cardiotocograph; NHSLA: National Health
Service Litigation Authority; CESDI: Confidential Enquiry into
Stillbirths and Deaths in Infancy; SROM: Spontaneous rupture
of membranes; NCT: National Childbirth Trust.
Speaker Biography
Caroline Everden qualified from St Bartholomew’s Hospital and The Royal London Hospital
in 2005. After starting her training in north-east London, she moved to Surrey in 2012.
She is currently a Obstetrician and Labor lead at Kingston Hospital with an interest in
ambulatory gynecology.
e:
caroline@everden.co.ukCaroline Everden
, Res Rep Gynaecol Obstet, Volume 3
DOI: 10.4066/2591-7366-C1-002