From January 2010 through December 2014, hospitals, ambulatory surgical facilities, birthing centers, and abortion facilities reported 8,569 events involving pregnant women to the Pennsylvania Patient Safety Authority. Of these reports, 1,031 involved an unplanned return to the operating room. These events most frequently occurred either at the beginning of pregnancy (generally related to termination of a pregnancy) or in the immediate postpartum period. The most frequently reported causes of pregnancy-related unplanned returns to the operating room included the following: incomplete abortion or abortion with a report of hemorrhage or perforation requiring a surgical procedure (44.7%); postpartum hemorrhage (28.4%); postpartum retention of placenta or products of conception (15.0%); postpartum laceration requiring surgical repair (7.6%); and other events (4.3%). Literature supports that those healthcare organizations that have implemented evidence-based systematic protocols and simulation-based education report better patient outcomes.
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