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Approach to Improving Safety
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Search results for "Active Errors"

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Journal Article > Commentary

Implementation of a modified bedside handoff for a postpartum unit.

Wollenhaup CA, Stevenson EL, Thompson J, Gordon HA, Nunn G. J Nurs Adm. 2017;47:320-326.

Ineffective team communication can contribute to sentinel events. This commentary describes how a rural hospital's postpartum unit redesigned its handoff process to create a bedside handoff model and utilized structured educational modalities and nurse champions to drive improvement and acceptance of the approach.

Newspaper/Magazine Article

The last person you'd expect to die in childbirth.

Martin N, Montagne R. ProPublica and National Public Radio. May 12, 2017.

Maternal mortality is increasing in the United States. This news article reports on this critical safety problem in the context of the preventable death of a patient whose diagnosis of preeclampsia was missed by her providers, despite persistent concerns raised by family about the patient's symptoms.

Cases & Commentaries

Don't Dismiss the Dangerous: Obstetric Hemorrhage

  • Spotlight Case
  • CME/CEU
  • Web M&M

Elliott K. Main, MD; November 2016

After an emergency cesarean delivery, a woman had progressive tachycardia and persistent hypertension. A CT scan showed no evidence of pulmonary embolism, but repeat blood tests showed a dangerously low hemoglobin level and markedly elevated liver enzyme levels. She was taken back to the operating room and found to have postpartum hemorrhage.

Journal Article > Commentary

How communication among members of the health care team affects maternal morbidity and mortality.

Brennan RA, Keohane CA. J Obstet Gynecol Neonatal Nurs. 2016;45:878-884.

Communication failures in obstetric care can increase risk of harm for the mother and the infant. This commentary highlights how nurses can incorporate teamwork principles and structured communication to reduce risks of maternal injury.

Journal Article > Study

Decreasing malpractice claims by reducing preventable perinatal harm.

Riley W, Meredith LW, Price R, et al. Health Serv Res. 2016;51(suppl 3):2453-2471.

Improving patient safety provides an opportunity to reduce malpractice claims and associated costs, particularly in higher risk clinical areas such as obstetrics. This study examined medical malpractice claims and cost data in the perinatal units of hospitals before and after implementation of safety interventions focused on decreasing perinatal harm. Interventions consisted largely of standardizing best practices and implementing team training. Investigators found that improving perinatal safety led to substantial reductions in both the frequency and total cost of malpractice claims. The role that the medical liability system plays in driving up health care costs and in promoting the practice of defensive medicine—which can lead to adverse events through unnecessary tests and procedures—was highlighted in a past WebM&M commentary.

Journal Article > Study

Use of temporary names for newborns and associated risks.

  • Classic

Adelman J, Aschner J, Schechter C, et al. Pediatrics. 2015;136:327-333.

Wrong-patient errors are considered to be never events. Newborns are assigned temporary names if they don't have a name immediately after birth, and this may increase the rates of wrong-patient errors. The need for first and last names in electronic health records has led to a generic first name convention of "Babygirl" or "Babyboy," which is in use in more than 80% of neonatal intensive care units in the United States. This pre-post study found that implementing specific first names that incorporated the mother's name reduced the incidence of wrong-patient errors by 36% compared to the generic naming. These errors are rare even at baseline, but given the ease of changing the naming convention, this is a pragmatic approach to improving the safety of computerized provider order entry for hospitalized newborns.

Journal Article > Commentary

Transforming communication and safety culture in intrapartum care: a multi-organization blueprint.

Lyndon A, Johnson MC, Bingham D, et al. Obstet Gynecol. 2015;125:1049-1055.

Poor communication among perinatal health care teams has been highlighted as a safety concern. Exploring human factors, leadership behaviors, and root causes that may contribute to miscommunication, this commentary recommends ways individual clinicians, team leaders, managers, organizations, and patients and their families can enhance safety in the labor and delivery setting.

Cases & Commentaries

Monitoring Fetal Health

  • Spotlight Case
  • CME/CEU
  • Web M&M

Mark W. Scerbo, PhD, and Alfred Z. Abuhamad, MD; January 2015

A woman who had an uncomplicated pregnancy and normal labor with no apparent signs of distress delivered a cyanotic, flaccid infant requiring extensive resuscitation. Although fetal heart rate tracings had shown signs of moderate-to-severe fetal distress for 90 minutes prior to delivery, clinicians did not notice the abnormalities on the remote centralized monitor, which displayed 16 windows, each for a different patient.

Journal Article > Review

Patient safety in obstetrics and obstetric anesthesia.

Kung A, Pratt SD. Int Anesthesiol Clin. 2014;52:86-110.

Labor and delivery (L&D) is a high-risk care environment where one error can lead to further breakdowns. This commentary suggests that L&D units provide ideal opportunities to study multifaceted approaches to avoiding errors. The authors outline various methods to improve safety in this setting, including strategies focused on standardized protocols, communication, teamwork, and simulation training.

Cases & Commentaries

Late Anemia Following Rh Disease in a Newborn

  • Web M&M

Thomas B. Newman, MD, MPH, and M. Jeffrey Maisels, MB, BCh, DSc; March 2014

Following delivery and successful phototherapy for hyperbilirubinemia, an infant developed anemia over the next few weeks. Found to have Rh hemolytic disease, the infant was admitted to the hospital for blood transfusion and close monitoring.

Journal Article > Commentary

Delivering the truth: challenges and opportunities for error disclosure in obstetrics.

Carranza L, Lyerly AD, Lipira L, Prouty CD, Loren D, Gallagher TH. Obstet Gynecol. 2014;123:656-659.

This commentary discusses unique barriers that affect error disclosure in obstetric care and reviews how efforts to enhance transparency can address liability concerns and improve patient-centered communication. Suggested interventions include disclosure training and implementing a just culture.

Journal Article > Commentary

Improved obstetric safety through programmatic collaboration.

Goffman D, Brodman M, Friedman AJ, Minkoff H, Merkatz IR. J Healthc Risk Manag. 2014;33:14-22.

This commentary describes how a four-hospital collaborative developed and disseminated best practices, mandated an online course for electronic fetal monitoring, provided team training, and incorporated feedback mechanisms to implement practice changes and augment safety in obstetric care.

Journal Article > Study

Ascension Health's demonstration of full disclosure protocol for unexpected events during labor and delivery shows promise.

Hendrich A, McCoy CK, Gale J, Sparkman L, Santos P. Health Aff (Millwood). 2014;33:39-45.

Full disclosure of medical errors has been described as both a great idea and an impractical risk management strategy. This case study evaluated Ascension Health's implementation of a full disclosure protocol during a 2-year period and found that staff support and compliance increased over time. A major barrier to widespread dissemination remains convincing liability insurers to support this type of program.

Journal Article > Study

Women's safety alerts in maternity care: is speaking up enough?

Rance S, McCourt C, Rayment J, et al. BMJ Qual Saf. 2013;22:348-355.

Programs to engage patients in safety encourage patients to speak up about their concerns; however, this study of maternity care patients found that staff are not always receptive when patients voice their concerns.

Journal Article > Commentary

A system-wide initiative to prevent retained vaginal sponges.

Chagolla BA, Gibbs VC, Keats JP, Pelletreau B. MCN Am J Matern Child Nurs. 2011;36:312-317.

This commentary describes how a 32-hospital system implemented a surgical sponge management program in the labor and delivery setting.

Journal Article > Commentary

Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery.

Lutgendorf MA, Schindler LL, Hill JB, Magann EF, O'Boyle JD. Mil Med. 2011;176:702-704.

This commentary discusses the development and implementation of a count procedure that successfully reduced incidence of retained sponges following labor and delivery.

Journal Article > Commentary

A simple checklist for preventing major complications associated with cesarean delivery.

Duff P. Obstet Gynecol. 2010;116:1393-1396.

This article proposes using an evidence-based checklist to prevent serious complications around pre-, peri-, and post-cesarean care.

Journal Article > Commentary

Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine.

Thyen AB, McAllister RK, Councilman LM. J Patient Saf. 2010;6:244-246.

This case report discusses how an error with no lasting patient harm served as a catalyst for organizational efforts on process improvement, protocol review, and safeguard enhancement to ensure safe delivery of epidural analgesia.

Journal Article > Study

More to teamwork than knowledge, skill and attitude.

Siassakos D, Draycott TJ, Crofts JF, Hunt LP, Winter C, Fox R. BJOG. 2010;117:1262-1269.

This study found that unidentified characteristics played a critical role in team effectiveness during simulated emergencies. The authors suggest traditional teamwork training programs may fail to account for these characteristics while focusing simply on specific knowledge or skills.

Cases & Commentaries

Acute Respiratory Arrest in Pregnancy

  • Web M&M

Baha Sibai, MD; June 2010

A woman with chronic hypertension developed undiagnosed preeclampsia during pregnancy with twins. At 38 weeks, she experienced respiratory and cardiac arrest. Although she eventually recovered, the infants were stillborn.

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