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Approach to Improving Safety
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Search results for "United States of America"

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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.

Journal Article > Review

Safety interventions on the labor and delivery unit.

Kacmar RM. Curr Opin Anaesthesiol. 2017;30:287-293.

The labor and delivery unit is a high-risk care environment. This review spotlights the importance of safety culture in obstetric care and describes strategies to improve safety in this setting, including simulation and case review.

Journal Article > Commentary

Clinical perspective: creating an effective practice peer review process—a primer.

Gandhi M, Louis FS, Wilson SH, Clark SL. Am J Obstet Gynecol. 2017;216:244-249.

Although peer review has been advocated as a valuable method for improving quality and practice, it has yet to be standardized to optimize its outcomes. This commentary discusses how to implement and assess the peer review process. The authors include case studies and other observations specific to obstetric and gynecologic practice to demonstrate the use of peer review as an organizational safety strategy.

Journal Article > Review

Huddles and debriefings: improving communication on labor and delivery.

McQuaid-Hanson E, Pian-Smith MCM. Anesthesiol Clin. 2017;35:59-67.

Labor and delivery units are high-risk environments where one miscommunication can lead to care breakdowns. This commentary discusses huddles as a strategy to reduce communication errors and debriefings as opportunities to learn from incidents and provide support for second victims.

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

Building comprehensive strategies for obstetric safety: simulation drills and communication.

Austin N, Goldhaber-Fiebert S, Daniels K, et al. Anesth Analg. 2016;123:1181-1190.

Most safety improvement interventions in obstetrics do not reflect insights from anesthesia providers. This commentary discusses how one hospital drew from the patient safety expertise of anesthesiologists and used simulation and communication interventions in its labor and delivery unit.

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

Is communication improved with the implementation of an obstetrical version of the World Health Organization safe surgery checklist?

Govindappagari S, Guardado A, Goffman D, et al. J Patient Saf. 2016 Sep 8; [Epub ahead of print].

Checklists have been shown to improve safety in the surgical setting. This retrospective chart review examined communication among staff members before and after implementation of an obstetric checklist for cesarean deliveries. Investigators found better agreement about reason for cesarean deliveries among the obstetric, anesthesiology, and pediatric staff after implementation of their checklist.

Journal Article > Commentary

National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism.

D'Alton ME, Friedman AM, Smiley RM et al. J Obstet Gynecol Neonatal Nurs. 2016;45:706-717.

Venous thromboembolism (VTE) is a preventable condition that can contribute to maternal harm. This expert commentary introduces a four-part strategy that focuses on standardization to help recognize and respond to VTE. The authors discuss the importance of reporting mechanisms to help health care organizations learn from events.

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 > 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.

Journal Article > Review

To the point: integrating patient safety education Into the obstetrics and gynecology undergraduate curriculum.

Abbott JF, Pradhan A, Buery-Joyner S, et al; APGO Undergraduate Medical Education Committee. J Patient Saf. 2016 Jul 26; [Epub ahead of print].

Incorporating patient safety education for medical students in various practice environments can enhance health care safety. This commentary describes efforts to integrate patient safety concepts into medical education and highlights the importance of including such curricula in obstetrics and gynecology. A past PSNet Annual Perspective discussed safety and medical education.

Journal Article > Study

Use of maternal early warning trigger tool reduces maternal morbidity.

Shields LE, Wiesner S, Klein C, Pelletreau B, Hedriana HL. Am J Obstet Gynecol. 2016;214:527.e1-527.e6.

Many organizations, including The Joint Commission and the National Partnership for Maternal Safety, recommend the use of early warning systems when treating maternity patients. This prospective study evaluated a maternal early warning trigger tool that was internally developed and piloted at six hospitals within a large health system. The tool was pathway specific and targeted the four most common causes of maternal morbidity: hemorrhage, preeclampsia, sepsis, and cardiac dysfunction. Severe maternal morbidity, as defined by the Centers for Disease Control and Prevention, and composite morbidity significantly decreased following implementation of this tool compared with both baseline rates and control hospitals. In 2010, The Joint Commission issued a sentinel event alert on preventing maternal death.

Journal Article > Review

Triggers, bundles, protocols, and checklists—what every maternal care provider needs to know.

Arora KS, Shields LE, Grobman WA, D'Alton ME, Lappen JR, Mercer BM. Am J Obstet Gynecol. 2016;214:444-451.

Obstetric care is recognized as a high-risk activity both for the mother and the infant. This review discusses several key methods to improve safety in maternal care, including checklists and trigger tools, and provides information for clinicians to implement these strategies.

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.

Journal Article > Review

Reducing adverse obstetrical outcomes through safety sciences.

Ennen CS, Satin AJ. UpToDate. August 27, 2015.

This review explores the evidence on integrating teamwork, simulation, and unit-based programs to improve safety in obstetrics settings. The authors highlight the need for more data regarding the impact of these approaches on patient outcomes.

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.

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