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Search results for "Labor and Delivery"
- Labor and Delivery
Journal Article > Study
Understanding the heterogeneity of labor and delivery units: using design thinking methodology to assess environmental factors that contribute to safety in childbirth.
Sherman JP, Hedli LC, Kristensen-Cabrera AI, et al; Safety Learning Laboratory for Neonatal and Maternal Care. Am J Perinatol. 2019 Apr 23; [Epub ahead of print].
This direct observation study examined maternal and neonatal care at 10 labor and delivery units. Investigators uncovered three environmental needs that impact safety: rapid access to blood products, space for neonatal resuscitation, and organization and availability of equipment and supplies. They conclude that applying design thinking to physical space could improve maternal and neonatal safety.
Journal Article > Review
Simpson KR, Lyndon A, Davidson LA. Nurs Womens Health. 2016;20:358-366.
Labor and delivery care is considered high risk for sentinel events should something go wrong. This review discusses how audible surveillance in this setting can contribute to alert fatigue and distraction among nurses and raises concerns that no standards exist to improve the effectiveness of electronic fetal monitoring.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. January 26, 2010;(44):1-4.
The Joint Commission issues Sentinel Event Alerts to highlight areas of high risk and to promote the rapid adoption of risk reduction strategies. Adherence to these recommendations is then assessed as part of Joint Commission accreditation surveys at health care organizations nationwide. This recently retired alert targets prevention of maternal death and highlights the need to manage blood pressure, pay attention to vital signs following cesarean delivery, and hemorrhage. The alert also provides recommendations around educational strategies, identifying specific clinical triggers for action, and conducting adequate risk assessments. As of September 2016, current guidance will being distributed by a new initiative.
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.