Perinatal Patient Safety Research Articles

Determining the Effectiveness of Online Communication Training in Nursing Students with the Sequential Mixed Method: An Example of Perinatal Patient Safety

Determining the Effectiveness of Online Communication Training in Nursing Students with the Sequential Mixed Method: An Example of Perinatal Patient Safety

Threats to Patient Safety in the Inpatient Maternity Setting.

As part of our special topics issue on inpatient maternity care, experts were asked to offer their thoughts about the main issues putting mothers and babies at risk in the maternity inpatient setting and what quality and safety practices may be beneficial in keeping them safe from harm. Each of the experts has a unique perspective. Loraine O'Neill was one of the original perinatal patient safety nurses who were established as part of an effort by a professional liability company to promote patient safety in birthing hospitals that they covered in several states (). She now is the perinatal patient safety officer in a large academic medical center in New York City. Lisa Miller is a well-known expert on fetal assessment during labor, certified nurse midwife, attorney, educator, patient safety expert, and editor of a popular fetal monitoring textbook (). She has taught fetal monitoring to nurses, midwives, and physicians in multidisciplinary groups all over the United States and consulted on numerous patient safety initiatives. Annie Rohan is a dual-certified neonatal and pediatric nurse practitioner with a 30-plus year clinical practice career with infants, children, and families facing critical and chronic illness. She is currently a healthcare researcher, and oversees advanced practice and doctoral nursing programs at SUNY Downstate Health Sciences University.

831: The effect of an oxytocin checklist for EMR clinical decision support in labor on oxytocin use and maternal/neonatal outcomes in a clinical practice setting

Oxytocin is associated with preventable adverse events during labor. Oxytocin dosing is complex due to a wide therapeutic index and lack of consensus on optimal dosing and regimen. In 2013, the Perinatal Patient Safety group within Kaiser Permanente Northern California created an oxytocin checklist to reduce and standardize dosing, first on paper then as a clinical decision support tool in the electronic medical record (EMR). We sought to assess the effect of the checklist on oxytocin usage and clinical outcomes over time. We performed a retrospective cohort study from October 2012 to December 2016 of 34,612 singleton gestations at 37w0d or greater who received oxytocin in labor. We compared oxytocin use (initial and highest infusion rates, average infusion rate, duration of use) and labor outcomes (admission to delivery time, operative delivery rate), for 3 groups: 1) pre-checklist implementation; 2) after paper checklist implementation; and 3) after implementation of EMR clinical decision support. We also examined infant outcomes (NICU admission, 5-minute Apgar <7, mechanical ventilation) and stratified by mode of delivery. Compared to pre-checklist, the paper checklist and decision support groups had a lower average and cumulative infusion rate, lower highest infusion rate, and longer duration of oxytocin use (Table). The change was greatest in the decision support group. The time from admission to delivery increased by 3.6 hours for the decision support compared to the pre-checklist groups. When stratifying by mode of delivery, findings were similar. The greatest change was seen in the cesarean delivery group, with a mean reduction of 760 mU of oxytocin and an increase of 4.7 hours between pre-checklist and decision support groups. The cesarean section rate and 5-minute Apgar <7, infant intubation, and infant length of stay were unchanged. Compared to pre-checklist, the decision support group was associated with a decrease in NICU admissions and in infants requiring oxygen after birth. Use of EMR clinical decision support with an oxytocin checklist is associated with improved clinical practice patterns and neonatal outcomes, at the expense of longer labor times.

Advancing perinatal patient safety through application of safety science principles using health IT

BackgroundThe use of health information technology (IT) has been shown to promote patient safety in Labor and Delivery (L&D) units. The use of health IT to apply safety science principles (e.g., standardization) to L&D unit processes may further advance perinatal safety.MethodsSemi-structured interviews were conducted with L&D units participating in the Agency for Healthcare Research and Quality’s (AHRQ’s) Safety Program for Perinatal Care (SPPC) to assess units’ experience with program implementation. Analysis of interview transcripts was used to characterize the process and experience of using health IT for applying safety science principles to L&D unit processes.ResultsForty-six L&D units from 10 states completed participation in SPPC program implementation; thirty-two (70%) reported the use of health IT as an enabling strategy for their local implementation. Health IT was used to improve standardization of processes, use of independent checks, and to facilitate learning from defects. L&D units standardized care processes through use of electronic health record (EHR)-based order sets and use of smart pumps and other technology to improve medication safety. Units also standardized EHR documentation, particularly related to electronic fetal monitoring (EFM) and shoulder dystocia. Cognitive aids and tools were integrated into EHR and care workflows to create independent checks such as checklists, risk assessments, and communication handoff tools. Units also used data from EHRs to monitor processes of care to learn from defects. Units experienced several challenges incorporating health IT, including obtaining organization approval, working with their busy IT departments, and retrieving standardized data from health IT systems.ConclusionsUse of health IT played an integral part in the planning and implementation of SPPC for participating L&D units. Use of health IT is an encouraging approach for incorporating safety science principles into care to improve perinatal safety and should be incorporated into materials to facilitate the implementation of perinatal safety initiatives.

Building a Successful Perinatal Patient Safety Program

Building a Successful Perinatal Patient Safety Program

Decreasing Malpractice Claims by Reducing Preventable Perinatal Harm.

To evaluate the association of improved patient safety practices with medical malpractice claims and costs in the perinatal units of acute care hospitals. Malpractice and harm data from participating hospitals; litigation records and medical malpractice claims data from American Excess Insurance Exchange, RRG, whose data are managed by Premier Insurance Management Services, Inc. (owned by Premier Inc., a health care improvement company). A quasi-experimental prospective design to compare baseline and postintervention data. Statistical significance tests for differences were performed using chi-square, Wilcoxon signed-rank test, and t-test. Claims data were collected and evaluated by experienced senior claims managers through on-site claim audits to evaluate claim frequency, severity, and financial information. Data were provided to the analyzing institution through confidentiality contracts. There is a significant reduction in the number of perinatal malpractice claims paid, losses paid, and indemnity payments (43.9 percent, 77.6 percent, and 84.6 percent, respectively) following interventions to improve perinatal patient safety and reduce perinatal harm. This compares with no significant reductions in the nonperinatal claims in the same hospitals during the same time period. The number of perinatal malpractice claims and dollar amount of claims payments decreased significantly in the participating hospitals, while there was no significant decrease in nonperinatal malpractice claims activity in the same hospitals.

Results from the National Perinatal Patient Safety Program in Sweden: the challenge of evaluation.

We studied the effects of the national Perinatal Patient Safety Program in Sweden, addressing local improvement measures, changes in the proportion of low Apgar score and the number of settled injury claims due to asphyxia. Final reports on achieved improvements from all Swedish obstetric units were analyzed and categories of the improvement measures taken in perinatal risk areas were established. Data on all term newborns during 2006-12 were obtained from the Medical Birth Registry. Incidence of 5-min Apgar score <7 was analyzed before, during and after the intervention. The odds ratio for low Apgar score in period ÍII vs. period I was calculated. Patient injury claims from The Swedish National Patient Insurance Company (LÖF) were analyzed. Numerous local improvement initiatives were reported. The incidence of 5-min Apgar score <7 on a national level remained unchanged during the study periods. The units with the highest rate of Apgar score <7 showed a significant decrease in Apgar score of 4-6 after the intervention, whereas units with the lowest rate of Apgar score <7 showed a significant increase in Apgar score <7 after the intervention. A decline in settled claims due to substandard care was observed (7.5%, 2012-14; p for trend 0.049). The national incidence of low Apgar score remained unchanged but a reduction of settled claims of severely asphyxiated neonates was observed. The study highlights the need for robust designs when evaluating large-scale initiatives for improving patient safety at delivery, along with the difficulties in performing them.

Setting Body Mass Index Criteria for Obese Obstetric Patients to Reduce Nurse Injury and Improve Patient Safety

Paper Presentation Purpose for the Program A high body mass index (BMI) in women during pregnancy poses safety threats for the nurses who care for them related to moving, transferring, repositioning, and airway management. There are also increased risks of adverse maternal and neonatal outcomes for morbidly obese women. In June 2013, an obstetric nurse injured her shoulder while assisting a morbidly obese woman. This incident sparked a response to investigate possible practice changes to ensure the safety of nurses who care for this patient population. Proposed Change To implement body mass index criteria in obstetric patients to reduce nurse injury and improve patient safety. Implementation, Outcomes, and Evaluation The Perinatal Quality and Patient Safety Collaborative is an interprofessional committee consisting of leaders from nursing, medicine, and anesthesiology. The committee reviewed opinions that were issued in January 2013 regarding obesity in pregnancy. The team set BMI limits for patients to ensure the safety of the patient and nursing staff during the birth process. The Roper St. Francis Healthcare Obesity in Pregnancy Guidelines state that assessment and counseling should be initiated early and when indicated, a multidisciplinary approach, including anaesthesia consultant, should be utilized. Anesthesia consults should be obtained for women with BMIs of 45–54.9. Women with BMIs of 55 or greater should give birth at a tertiary care center. Additional lift equipment was purchased to help nurses transfer and position women without harming themselves. Because the first injury occurred during the transfer of a morbidly obese patient from a bed to the operating room table, a Maxi Air Mattress with air supply was ordered in December 2013 to help reduce injuries. Implications for Nursing Practice The committee continues to monitor the BMI of women who give birth at Bon Secours St. Francis Hospital to ensure that the guidelines are being followed. Since 2014, an average of seven women per month are seen prenatally for anesthesia consults to discuss patient safety issues and maternal and neonatal risks. In addition to the reduction in injuries, 10 morbidly obese women were transferred to the tertiary care center from November 18, 2013 to July 23, 2014. This provides safer deliveries and recoveries for these women and helps to prevent possible staff injuries.

Reducing Pregnancy‐Related Morbidity and Mortality by Implementing a Comprehensive Quality and Patient Safety Program Beyond the Joint Commission's Perinatal Core Measures

Paper Presentation Purpose for the Program To reduce pregnancy‐related morbidity and mortality in a large, academic, high‐risk obstetric service in a large, free‐standing, pediatric hospital in the southwestern United States. Proposed Change To develop and implement an evidence‐based perinatal quality and patient safety program. Implementation, Outcomes, and Evaluation An interprofessional team reviewed the literature to identify evidence‐based structures and processes that were associated with increased process reliability and improved patient safety outcomes. With support and approval from senior‐level organization leaders and strong partnerships with key stakeholders, the program was implemented in the spring of 2012. Key structures included safety as a core value and nurse staffing and educational preparation. Key processes included daily safety briefs, safety rounds, interprofessional team simulation training, and adherence to evidence‐based care guidelines. To augment the quality and safety program and to address active and latent threats to patient safety identified during event debriefs and safety rounds, an interprofessional subgroup developed and implemented a massive transfusion protocol. The rate of obstetric adverse events (OBAE) was selected as the program's outcome measure. The OBAE rate is a composite measure of quality and comprises eight maternal and four fetal measures, calculated as the number of monthly deliveries complicated by one or more maternal or fetal adverse events, multiplied by 100. The baseline rate of OBAE through November of 2012 was 2.01%. During the next 12 months, despite a rapidly increasing delivery volume, the OBAE was reduced 37%. As of August 2014, the OBAE rate in this obstetric service was 1.05%, which reflects an additional 17.3% reduction. Implications for Nursing Practice Although obstetric patient care is delivered by teams, nurses are in a unique position to guide, influence, and lead quality and safety improvements. Nurses have nearly constant presences, are broadly trusted as patient advocates, and are able to identify and report early signs of compromise. Supported by a comprehensive quality and patient safety program in partnership with other key members of the obstetric patient care team, nurses can reduce pregnancy‐related morbidity and mortality.

Simulation Training to Improve Competency and Confidence at the University of California San Diego, Women and Infants Services

Poster Presentation Purpose for the Program To improve nursing and health care provider staff competence and confidence in response to emergency events using simulation training events (STE). The initial data collected between 2011 and 2012 indicated that 70% of staff felt confident in participating in STEs; 62% demonstrated poor communication and slow response time in obstetric emergencies. No STEs were performed or offered, and no resident/intern/fellow and nursing staff participated in STEs. Proposed Change To increase physician/provider and nursing staff comprehension of simulation education and training along with demonstration of competency to improve patient safety in obstetrics (OB). Participant comprehension of simulation education and training will be demonstrated by a pretest and posttest. Participant competency will be demonstrated by improved response time and communication. Implementation, Outcomes, and Evaluation This program was implemented by the labor and delivery (LD at least an annual 5% increase was demonstrated regarding improved communication and response time in obstetric emergencies; 20 STE drills were conducted over the course of the year; and 90% of faculty and staff participated in a simulation training session within a year of evaluation. Implications for Nursing Practice Perinatal patient safety initiatives are of national interest. Collaboration among multidisciplinary providers and nursing staff is necessary, and improving communication and practicing emergency responses has been shown to improve outcomes. STEs have been shown to be a successful method to improve the response time, competence, confidence, and communication of teams. Because nursing staff spends the most time at the bedside and plays a major role identifying mother/infant decompensation, it is essential to maintain competence in emergency response.

The Effect of Collaboration on Obstetric Patient Safety in Three Academic Facilities

Interprofessional collaboration is critical to the provision of safe patient care and provider satisfaction. Collaboration is an active process that can help maximize positive patient outcomes. Three academic institutions implemented collaborative processes as part of their perinatal patient safety initiatives based on anecdotal experiences and safety culture surveys that demonstrated positive outcomes. Reliable tools and additional research are needed to measure the extent and impact of collaboration on patient outcomes in perinatal care.

Improving Perinatal Patient Safety among Turkish Nursing Students Using Simulation Training

The aim of this study was to determine whether simulation training is an appropriate and affective teaching method to be used in perinatal patient safety nursing.The study was carried out in the Nursing Department of the Faculty of Medical Sciences of Baskent University in the academic year of 2008-2009. A pre-test/ post-test design was used. Experimental group exposed to simulation training as well as following their normal curriculum. The results of the study indicate the students’ in the simulation group generally obtained higher marks than those in the didactic classroom education We concluded that simulation could play a key role in allowing students to develop their clinical decision-making skills within a safe learning environment and educational activities involving simulation are more effective than traditional teaching methods.

Got Code Pink? Neonatal Code Response Team

Poster Presentation Purpose for the Program Effective communication and collaboration among the clinical team is essential to optimize perinatal patient safety during the delivery of emergent care to a neonatal patient. In more than 80% of perinatal deaths and injuries, communication concerns have been identified by the Joint Commission on Accreditation of Health Care Organizations (JCAHO) as the most frequent identified root cause. was created to optimize outcomes and prevent failure to rescue. Proposed Change Based upon the recommendation from the Joint Commission and needs assessment of the perinatal staff, a Midwestern level II family‐birth center examined, developed, simulated, and then adapted an algorithm for the assignment of the procedural roles needed to provide care during a neonatal emergency, titled Pink. Implementation, Outcomes, and Evaluation The implementation of the Code Pink algorithm identifies specific procedural roles for the entire unit during a neonatal emergency. Within the algorithm there is a telephone triage to ensure that the ancillary departments are notified. The Code Pink algorithm also includes a shift assignment of the following procedural roles: fetal monitor watcher, medications/crash cart, chest compressions, recorder, airway, and runner. These roles are fulfilled by registered nurses who have completed the Neonatal Resuscitation Program (NRP). The role of runner is assigned to perinatal patient care assistants who have completed NRP. To activate the Code Pink algorithm any staff member presses our staff emergency button, located in every room, which alerts every staff member's wireless telephone with the room number. The algorithm is then followed and all staff know their assigned roles of the Code Pink team, and if necessary staff will telephone ancillary departments, including respiratory, special care nursery, neonatology, and anesthesia. The algorithm has been practiced and simulated numerous times, with each simulation focusing on interdisciplinary communication and role identification. Since the creation of the Code Pink algorithm/team there have been no role‐based communication errors and no failure rescue events. Implications for Nursing Practice Adherence to the Code Pink algorithm provides for rapid intervention at the time of care when the patient, and other patients on the unit, need seamless and collaborative care. With the application of the Code Pink algorithm into nursing practice, patient care and staff communication of emergent roles and expectations are optimized. This organized, team‐based care process has improved delivery of care through the creation of an algorithm and environment that is clearly focused on patient safety and communication among an entire staff during obstetric emergencies.

Implementing Enterprise-Wide Electronic Fetal Monitoring Certification for All Perinatal Clinicians

The Trinity Health Perinatal Patient Safety Initiative was launched in March 2009 to improve safety for mothers and infants. Trinity Health is a large Catholic health system with 25 hospitals that provides obstetric services, with annual births ranging from 50 to 8,500. The total number of deliveries for Trinity Health in 2010 was 38,656, which is approximately 1% of the nation's deliveries. Nationally, one of the most frequent allegations in perinatal malpractice claims is delayed diagnosis of an indeterminate/abnormal fetal heart rate tracing.

Do You See What I See? A Collaborative Nurse/Physician Approach to Fetal Monitoring

Electronic fetal monitoring has recently been the subject of many perinatal patient safety initiatives. The American College of Obstetricians and Gynecologists (ACOG) released a Practice Bulletin in 2009 addressing electronic fetal monitoring terminology updates, interpretation, and management. Evidence indicates that fetal monitoring is often a factor in obstetric lawsuits. A review of the literature also shows that poor communication is a primary factor in sentinel events. Therefore, our facility initiated a protocol to ensure appropriate interpretation and management of fetal monitor tracings.

Michigan Health & Hospital Association Keystone Obstetrics: A Statewide Collaborative for Perinatal Patient Safety in Michigan

Preventable harm to mothers and infants during labor and birth is a significant patient safety and professional liability issue. A Michigan Health & Hospital Association Keystone Center for Patient Safety & Quality Obstetric Collaborative Project involved perinatal teams from 15 Michigan hospitals during an 11-month period in 2009. The purpose of the project was to promote safe care practices during labor and birth using the Comprehensive Unit-based Safety Program (CUSP). Consistent with the CUSP model, this project's components included assessing and promoting a culture of safety; interdisciplinary team building; case review; learning from defects through multiple methods of education; team and individual coaching and peer encouragement; administrative support for the establishment of a fundamental safety infrastructure; and ongoing evaluation of care processes and outcomes. Study measures included 32 components of a perinatal patient infrastructure, 6 care processes during labor and birth, and 4 neonatal outcomes. Significant improvements were found in the safety culture (Safety Attitudes Questionnaire), the perinatal patient safety infrastructure components, and all care processes. Although the project was successful, getting buy-in from all members of the clinical team in each hospital for all of the measures was challenging at times. There was initial resistance to some of the measures and their various expected aspects of care. For example, some of the clinicians were initially reluctant to adopt the recommended standardized oxytocin protocol. Peer encouragement and unit-based feedback on progress in minimizing early elective births proved useful in many hospitals. A CUSP in obstetrics can be beneficial in improving the care of mothers and infants during labor and birth.

The Perinatal Safety Nurse

There is increased attention to the issue of patient safety in the care of pregnant women and their infants. The Joint Commission has issued sentinel event alerts regarding infant and maternal morbidity and mortality. Hospitals and healthcare systems are implementing perinatal patient safety programs to minimize the risk of preventable patient harm. This article describes the role of the perinatal patient safety nurse as one aspect of a comprehensive initiative to promote patient safety for women who give birth. Nurses and organizations offering perinatal care are encouraged to incorporate the role of perinatal patient safety nurse in their patient safety efforts.

Implementing a System-Wide Perinatal Patient Safety Initiative

Trinity Health is the fourth largest Catholic health system in the United States with 19 Ministry Organizations encompassing 47 hospitals, 379 outpatient clinics and numerous long-term, home health, hospice and other facilities in eight states. There are 26 hospitals that provide obstetric services with annual births ranging from 50 to 8,400. In 2008, Trinity Health Executive Team launched the Perinatal Patient Safety Initiative (PPSI) to standardize high-risk obstetric processes to improve safety and the quality of care provided to mothers and babies at each of the Ministry Organizations.

Perinatal Patient Safety and Quality

The leadership team and clinicians in hospitals and healthcare system must focus on perinatal safety and quality to minimize risk of preventable harm to mothers and infants. A review of current issues in perinatal patient safety and quality is presented.

Risk Management Handbook for Health Care Organizations

Risk Management Handbook for Health Care Organizations