Root Cause Analysis of factors related to the death of newborns hospitalized in public maternities in Argentina.

Abstract

BACKGROUND: The infant and neonatal mortality rate in Argentina is decreasing but disparities between regions are notable and 60 per cent of the newborn deaths (NB) are preventable. OBJECTIVE: to analyze a set of neonatal deaths through standardized techniques and root cause analysis (RCA). The RCA is a reactive tool to identify factors contributing to the occurrence of an unwanted event in search of system failures. Design: multicentric observational cross-sectional study. METHOD: NB ≥ 500grs who died ≤ 30 days in 2008–2009 in 6 maternity hospitals in Argentina were included. Data collection was multidimensional and close to the death with chronological analysis and assessment of dimension institutional, human resources, equipment, physical environment and external factors. Every NB was epidemiologically characterized and an advisory group classified death as inevitable or reducible. RESULTS: 369 deaths were analyzed; the main hospitalization causes were respiratory distress (67.7%), malformations (16.2%), infections and perinatal asphyxia (12%). The human resources dimension was the most frequently related to the death (59%), followed by the institutional and organizational (48%). 57.7% of deaths were classified as reducible. The neonatal transport condition (OR 1.97 CI95% 1, 01-3, 83), the presence of complications (OR 8,56 CI95% 5,03-14,5) and age > 6 days (OR2 CI95% 1,06-3, 95) were associated with neonatal death reducibility independently. CONCLUSIONS: most of neonatal deaths were reducible. It is essential to establish strategies for training and strengthening human resources that assist this population.