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Search results for "Health Care Executives and Administrators"

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  • Health Care Executives and Administrators
  • Obstetrics
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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.

Journal Article > Commentary

ACOG Committee Opinion #681: disclosure and discussion of adverse events.

ACOG Committee on Patient Safety and Quality Improvement and Committee on Professional Liability. Obstet Gynecol. 2016;128:e257-e261.

Disclosure of errors and adverse events is now endorsed by a broad array of organizations. This statement discusses the importance of disclosure and provides resources to help health care organizations develop policies and programs that support a blame-free, learning approach to error that encourages reporting.

Journal Article > Study

Integrated approach to reduce perinatal adverse events: standardized processes, interdisciplinary teamwork training, and performance feedback.

Riley W, Begun JW, Meredith L, et al. Health Serv Res. 2016;51(suppl 3):2431-2452.

Prior research has shown that reducing preventable perinatal harm leads to a decrease in malpractice claims. In this prospective study involving the perinatal units across 14 hospitals from 12 states and accounting for almost 350,000 deliveries, researchers found that successful implementation of 3 standard care processes resulted in a 14% decrease in harm in perinatal care from the baseline period.

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 > Review

Patient safety implications of electronic alerts and alarms of maternal–fetal status during labor.

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.

Journal Article > Study

A 'busy day' effect on perinatal complications of delivery on weekends: a retrospective cohort study.

Snowden JM, Kozhimannil KB, Muoto I, Caughey AB, McConnell KJ. BMJ Qual Saf. 2017;26:e1.

This study found that perinatal complications of childbirth, including low Apgar scores, neonatal seizures, and postpartum hemorrhage, were more prevalent during the weekend, echoing the weekend effect in other health settings. Higher patient volume was also associated with worse outcomes, consistent with prior studies of nurse staffing ratios. These results argue for staffing changes to ensure safety at busy times and outside usual business hours.

Book/Report

Each Baby Counts: Key Messages from 2015.

London, UK: Royal College of Obstetricians and Gynaecologists; 2016.

This report highlights the importance of in-depth reporting and investigation of adverse events in labor and delivery, involving parents in the analysis, engaging external experts to gain broader perspectives about what occurred, and focusing on system factors that contribute to failures. A WebM&M commentary discusses how lapses in fetal monitoring can miss signs of distress that result in harm.

Journal Article > Study

Association between day of delivery and obstetric outcomes: observational study.

Palmer WL, Bottle A, Aylin P. BMJ. 2015;351:h5774.

The weekend effect, in which adverse events occur more commonly outside of normal working hours, has been noted across multiple health care settings. In this retrospective observational study, investigators examined maternal and neonatal quality measures for deliveries occurring on Tuesdays compared with deliveries during the weekend. They found that four of seven performance measures studied were worse during the weekend, but staffing levels did not seem to explain the higher complication rate on weekends. This study is consistent with prior work suggesting patient safety vulnerabilities during the weekend, but further investigation of the weekend effect is required.

Journal Article > Study

Implementing an obstetric emergency team response system: overcoming barriers and sustaining response dose.

Richardson MG, Domaradzki KA, McWeeney DT. Jt Comm J Qual Patient Saf. 2015;41:514-521.

This study describes the introduction of a rapid response system (RRS) on a high-risk obstetric unit at a large academic medical center. The number of RRS activations over the first 3 years has steadily increased, which the researchers consider a marker of successful RRS integration.

Cases & Commentaries

Abdominal Pain in Early Pregnancy

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

Charlie C. Kilpatrick, MD; September 2015

After several days of abdominal pain, nausea, and vomiting, a pregnant woman visited the emergency department and was swiftly discharged with antibiotics for a UTI. However, she returned the next day with unchanged abdominal pain and more nausea and vomiting. Apart from a focused ultrasound to document her pregnancy, no further testing was done. The patient again returned the following day with increased pain and now appeared more ill. An MRI revealed a ruptured appendix.

Journal Article > Commentary

Obstetric safety and quality.

Pettker CM, Grobman WA. Obstet Gynecol. 2015;126:196-206.

Obstetric hospital admission has substantial potential for harm should something go wrong. Summarizing the unique characteristics of obstetric care that affect quality and safety, this commentary highlights strategies to improve safety in this setting, including Plan-Do-Study-Act cycles, simulation training, and crew resource management.

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.

Journal Article > Review

Team training for safer birth.

Cornthwaite K, Alvarez M, Siassakos D. Best Pract Res Clin Obstet Gynaecol. 2015;29:1044-1057.

Obstetric care is considered a high-risk environment. Highlighting the importance of coordinated teamwork during obstetric emergencies, this review discusses strategies to augment clinical outcomes in this setting, including team training, communication improvement, and situational awareness.

Newspaper/Magazine Article

Is incivility an underlying threat to safety in obstetrics?

Veltman L. Patient Saf Qual Healthc. January/February 2015;12:34-36.

The Joint Commission and the American College of Obstetricians and Gynecologists have issued guidance regarding disruptive behaviors among clinicians. This magazine article provides an overview of incivility or disrespectful behavior in health care, how it can affect patient safety, and strategies to prevent such behaviors in the obstetrics and gynecology setting.

Journal Article > Commentary

ACOG Committee Opinion #621: patient safety and health information technology.

ACOG Committee on Patient Safety and Quality Improvement; Committee on Practice Management. Obstet Gynecol. 2015;125:282-283.

Despite improvements associated with health information technology (IT), consistently safe use has been difficult to achieve. This guideline describes the benefits and challenges associated with various components of health IT and suggests that enhanced interoperability and mandatory reporting for health IT errors are needed to improve safety.

Journal Article > Commentary

Developing a systematic approach to safer medication use during pregnancy: summary of a Centers for Disease Control and Prevention–convened meeting.

Broussard CS, Frey MT, Hernandez-Diaz S, et al. Am J Obstet Gynecol. 2014;211:208-214.e1.

This commentary summarizes findings from a multidisciplinary panel, convened as part of a broad-based obstetric medication safety improvement initiative, which discussed best practices to identify, evaluate, and disseminate evidence with the goal of providing guidance on these processes and developing a systematic approach for other teams initiating similar efforts.

Journal Article > Commentary

Committee opinion no. 590: preparing for clinical emergencies in obstetrics and gynecology.

American College of Obstetricians and Gynecologists Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2014;123:722-725.

This guideline details strategies to ensure care teams in obstetrics and gynecology are prepared to safely manage emergencies. Recommendations include incident debriefings, early warning systems, rapid response systems, and structured communication tools.

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.

Journal Article > Study

The effect of a program to shorten the decision-to-delivery interval for emergent cesarean section on maternal and neonatal outcome.

Weiner E, Bar J, Fainstein N, et al. Am J Obstet Gynecol. 2014;210:224.e1-6.

Enhancing teamwork and communication are key strategies to prevent errors in surgical care. In this study, introducing a management protocol that included event debriefs shortened the time elapsed between deciding to and performing a cesarean delivery, resulting in improved neonatal outcomes.

Book/Report

The Report of the Morecambe Bay Investigation.

Kirkup B. London, UK: The Stationery Office; 2015. ISBN: 9780108561306.

Sharing information about large-scale investigations into failures can provide insights on factors that contribute to adverse clinical incidents. This report discusses an analysis of care delivered in the maternity unit of a National Health Service Trust between 2004 and 2013 which uncovered problems that were perpetuated due to failure to look into the initial event.

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