Background: In complex healthcare organizations, such as intrapartum care, both patient safety culture and teamwork are important aspects of patient safety. Patient safety culture is important for the values and norms shared by interprofessional teams in an organization, and such values are principles that guide team members’ behavior. The aim of this study was 1) to investigate differences in perceptions of patient safety culture and teamwork between professions (midwives, physicians, nursing assistants) and between labor wards in intrapartum care and 2) to explore the potential associations between teamwork and overall perceptions of patient safety and frequency of events reported. Methods: The design was cross-sectional, using the Swedish version of the Hospital Survey on Patient Safety Culture (14 dimensions) and the TeamSTEPPS® Teamwork Perceptions Questionnaire (5 dimensions). Midwives, physicians, and nursing assistants in three labor wards in Sweden in 2018 were included. Descriptive statistics, the Kruskal–Wallis H test, two-way ANOVA, and standard multiple regression analysis were used. Results: The questionnaires were completed by 184 of the 365 healthcare professionals, giving a response rate of 50.4%. Two-way ANOVA showed a significant main effect of profession on two patient safety culture dimensions and one teamwork dimension and a significant main effect of labor ward on four patient safety culture dimensions and four teamwork dimensions. A significant interaction effect of profession and labor ward was found on four patient safety culture dimensions and four teamwork dimensions. The regression analysis revealed that four out of the five teamwork dimensions explained 40% of the variance in the outcome dimension ´Overall perceptions of patient safety´. Conclusions: The results of the study indicate that profession and labor ward are important for healthcare professionals' perceptions of patient safety culture and teamwork in intrapartum care. Teamwork perceptions are significant for overall patient safety. 

The overall aim of the thesis was to describe adverse events for women with planned vaginal births and healthcare professionals’ perceptions of patient safety. Further, to test the reliability and validity of a teamwork questionnaire and to investigate patient safety culture and teamwork among healthcare professionals in intrapartum care.

Methods: Paper I had a retrospective design, with 311 birth record reviews. Paper II had a descriptive and qualitative design using a phenomenographic approach, including interviews with 19 healthcare professionals in three labor wards. Paper III and IV had cross-sectional designs. Healthcare professionals’ (n=450) in various wards responded to the TeamSTEPPS® Teamwork Perceptions Questionnaire (T-TPQ) (III). Healthcare professionals’ (n=184) in three labor wards responded to the Swedish version of the Hospital Survey on Patient Safety Culture and the T-TPQ (IV). Confirmatory factor analysis and descriptive and inferential statistics were used.

Main results: Adverse events in women occurred in 11% of planned vaginal births (I). Four descriptive categories with nine perceptions described patient safety for women giving birth (II). Confirmatory factor analysis of the T-TPQ indicated a good fit (III). Main and interaction effects of profession and labor ward on patient safety culture and teamwork were found (IV).

Conclusions: The results highlight the occurrence of 3rd- or 4th-degree lacerations, distended urinary bladder, and anesthesia-related adverse events. For safe care, it is crucial for healthcare professionals to provide supportive care and to listen to the woman. Using team members’ competences in a tolerant atmosphere, with a reasonable workload, and learning from failure as well as from success are preconditions for patient safety. The Swedish version of the T-TPQ shows acceptable reliability and validity. Differences between labor wards seemed to have a greater impact than differences between professions on patient safety culture and teamwork.

Patient safety is a global health priority. Knowledge about patient safety and adverse events for women giving birth is necessary. Patient safety culture and effective teamwork are important for safe care provided by midwives, physicians and nursing assistants. The overall aim of the thesis was to describe adverse events for women with planned vaginal births and healthcare professionals’ perceptions of patient safety. Further, to test the reliability and validity of a teamwork questionnaire and to investigate patient safety culture and teamwork among healthcare professionals in intrapartum care. A birth record review, interviews and two questionnaires were used. Adverse events were identified in 11% of the birth records, but no permanent harm. Listening to the woman and having a tolerant teamwork atmosphere were important. Both profession and labor ward are important for healthcare professionals’ perceptions of patient safety culture and teamwork in intrapartum care.

Background Childbirth could negatively affect the woman's health through adverse events. To prevent adverse events and increase patient safety it is important to detect and learn from them. The aim of the study was to describe adverse events, including the preventability and severity of harm during planned vaginal births, in women giving birth in the labor ward. Methods The study had a descriptive design with a retrospective birth record review to assess the preventability of adverse events using the Swedish version of the Global Trigger Tool. The setting was a labor ward in Sweden with low-risk and risk childbirths. Descriptive statistics, Pearson's Chi-square test and Student's t-test were used. Results A total of 38 adverse events (12.2%) were identified in 311 reviewed birth records. Of these, 28 (73.7%) were assessed as preventable. Third- or fourth-degree lacerations and distended urinary bladder were most prevalent together with anesthesia-related adverse events. The majority of the adverse events were classified into the harm categories of 'prolonged hospital care' (63.2%) and 'temporary harm' (31.6%). No permanent harm were identified, but over two-thirds of the adverse events were assessed as preventable. Conclusions This first study using Global Trigger Tool in a labor ward in Sweden identified a higher incidence of adverse events than previous studies in obstetric care. No permanent patient harm was found, but over two-thirds of the adverse events were assessed as preventable. The results draw particular attention to 3(rd)-or 4(th)-degree lacerations, distended urinary bladder and anesthesia-related adverse events. The feedback on identified adverse events should be used for systematic quality improvement and clinical recommendations how to prevent adverse events must be implemented.

Aim:To describe healthcare professionals' perceptions of patient safety with a focus on the woman in connection to childbirth.Design: A descriptive and qualitative design with a phenomenographic approach.Methods: Individual qualitative face-to-face interviews with 19 healthcare professionals (midwives, nursing assistants and physicians) were conducted in three labour wards in Sweden. The data were analysed according to Dahlgren and Fallsberg's seven steps.Results: The informants' perceptions of patient safety for the women were identified in four qualitative different descriptive categories: Safeguarding the woman, Safeguarding the birth process, Respecting the individual and the team and Managing workforce and learning. Supportive care and listening to the woman were important for patient safety. It was crucial to follow labour stages and to avoid unnecessary interventions. An open and tolerant atmosphere between the healthcare professionals improved decision-making, and a reasonable workload was essential for ensuring safe care.

Purpose: The delivery of effective and safe healthcare to patients is highly dependent on careful collaboration between healthcare professionals. Although teamwork is an important component for patient safety, effective teamwork is not always carried out in hospital wards, leading to negative consequences for the patients. Teamwork measurements can be used to evaluate and provide feedback to healthcare professionals to support team performance and to identify areas for improvement. The TeamSTEPPS (R) Teamwork Perceptions Questionnaire (T-TPQ) evaluates Team Structure and four core competences of teamwork (Leadership, Situation Monitoring, Mutual Support, and Communication) among healthcare professionals in various healthcare settings. The questionnaire was judged to be relevant in a Swedish healthcare context and was translated into Swedish. This study aimed to test the reliability and construct validity of the Swedish version of the T-TPQ. Methods: A total of 450 (of 1176) frontline healthcare professionals working at four hospitals responded to the questionnaire. A confirmatory factor analysis was carried out to test the factor structure. Cronbach's alpha was used to measure internal consistency. Results: The hypothesized five-factor model of the five dimensions showed acceptable goodness-of-fit indexes. Cronbach's alpha coefficient for the total T-TPQ was 0.94, and the Cronbach's alpha coefficients for the dimensions ranged from 0.79 to 0.92. The intercorrelation coefficients ranged from 0.27 to 0.74. Conclusion: The Swedish version of the T-TPQ showed acceptable reliability and validity for measuring healthcare professionals' individual perceptions of teamwork at the group level. Due to the low response rate, further studies are required to test the validity of the Swedish T-TPQ.

Fosterövervakning är en komplex och kommunikationsavhängig verksamhet i barnmorskors dagliga arbete på förlossningskliniker. En svensk studie har visat att det brister i följsamhet till riktlinjer för fosterövervakningen. Det finns enligt min kunskap inga studier som, ur ett konstruktionistiskt perspektiv belyser kvaliteten i förlossningsklinikers dokument för riktlinjer och rutiner. Syftet med studien är att därför undersöka hur patientsäkerhet framställs i rutin-dokument för fosterövervakning.

Två medelstora förlossningskliniker i Sverige har ställt sina rutindokument om fosterövervak-ning till förfogande. Metoden har diskursanalytisk ansats och en modell för textgranskning har använts. Analyser av de båda rutindokumenten har resulterat i synteser, som relaterats till patientsäkerhet i huvudsak.

Resultatet visar att risker för hypoxiutveckling hos fostret under förlossningen eller risker an-gående tolkningsmomentet inte är tydligt beskrivna eller problematiserade. Detta trots att re-gistreringen vid fosterövervakning kan vara svårbedömd eftersom den ska tolkas och sättas in i ett större sammanhang. Tillstånd som ökar hypoxirisken beskrivs inte, det vill säga ett pro-cessperspektiv på CTG-användningen kan inte identifieras. Kommunikationsfrågor hanteras otydligt. Det ena rutindokumentet innehåller riskfaktorer som påbjuder kontinuerlig CTG, men risker i samband med värkstimulering har en oförtjänt undanskymd plats.

Patientsäkerhet konstrueras och framställs sammanfattningsvis inte tillfredsställande i rutin-dokumenten.

Fetal monitoring is a complex procedure and depends on the quality of the communication in midwives daily work at maternity clinics. A Swedish study has shown that there is a lack of adherence to guidelines for fetal monitoring. There are, to my knowledge, no studies made from a constructionist perspective that highlight the quality of such guidelines. The aim of the study is to examine how patient safety is represented in the routine documents for fetal moni-toring.

Two medium-sized obstetric clinics in Sweden have accepted to let their routine documents about fetal monitoring be available for assessment. A discourse analytic approach and a model for text analysis have been used as a method. Analysis of the two routine documents has resulted in the syntheses, mainly related to patient safety.

The result shows that risks for developing fetal hypoxia during labor and risks concerning in-terpretation element is not clearly described or problematized. Despite the fact that the regis-tration of fetal monitoring, it can be difficult to assess, because it is interpreted and put in a larger context. Conditions that increase the risk of hypoxia are not described, that is, a process perspective on the CTG-use can not be identified. Communications are handled unclear. One routine document contains risk factors which dictate continuous CTG, but that risk related to stimulation of the contractions had a secluded spot.

As a conclusion, in the routine documents patient safety is not satisfactory nor constructed or considered.