OB Guideline 34: Reporting of Adverse Outcomes

Routine screening for adverse outcomes shall be conducted at each institution for the purpose of capturing untoward outcomes, determining trends, developing corrective action, and providing timely information. The following patient outcomes should be reported to the institution’s risk management and quality assurance personnel as soon as possible.

Infant Condition or Complication

• Apgar score of 5 or less at five minutes
• Brachial plexus palsy
• Congenital deformity or birth injury leading to incapacity or disability¹
• Cord pH less than 7.0
• Fracture of any long bone (excluding clavicle)
• Fractured skull
• Infant abduction
• Intracranial bleed unrelated to prematurity
• Meconium aspiration
• Neonatal seizures within the first 48 hours
• Respiratory distress syndrome after elective induction or elective repeat cesarean delivery
• Stillbirth or neonatal death in fetuses >24 weeks or >500 grams
• Surgical injury, including laceration of infant
• Term infant (>36 weeks) >2, 500 grams admitted for >24 hours to Level II or Level III nursery
• Unconsented circumcision
• Admission/transfer to NICU of a newborn for therapeutic hypothermia (see Guideline 32)

Birthing Person Complications

• Death
• Eclampsia
• Failure to perform planned procedure
• Hysterectomy
• Birthing person readmission within two weeks of discharge
• Need for return to delivery room or operating room for unplanned procedure
• Retained sponge, instrument, or needle
• Surgery done on the wrong person or the wrong organ
• Surgical or delivery injuries, including burns and nerve injuries
• Symptomatic uterine rupture
• Unconsented procedure
• Unplanned transfer to intensive care

Peer review of adverse fetal or birthing person outcomes conducted pursuant to an institution’s bylaws is, by law, confidential.

Institutional Responsibility

Events identified as being serious reportable events (SREs) must be reported by the institution to the Commonwealth of Massachusetts Executive Office of Health and Human Services
Department of Public Health.¹

Each obstetrical institution is responsible for developing policies and procedures for disclosure to patients of adverse events and outcomes involving their care.²

1. Massachusetts Department of Public Health website for reportable incidents. Available at: http://www.mass.gov/dph
2. If an adverse event occurs. CRICO. Available at: What to do After an Adverse Event, (https://www.rmf.harvard.edu/Risk-Prevention-and-Education/Article-Catalog-Page/Articles/2009/What-to-do-After-an-Adverse-Event)