|Perinatal Deaths -A call for teamwork||17644||60||7/2/2012 6:00:00 AM||Obstetrics & Gynecology||United States of America||Maryland Office of Healthcare Quality (USA)||This alert describes and discusses fatal patient safety incidents of perinatal deaths. Three incidents are described providing contributing factors or causes as well as recommendations for improvement. This Clinical Alert attempts to raise awareness of these tragic events by examining some of the commonalities in cause and effect between the events reported since January 1, 2011. Rather than focus on the birth process itself, it may be more helpful to focus on more generic causes such as inadequate communication and poor teamwork. All of the reported perinatal events included peer review as a separate track in the aftermath of the event. All events seem to be examples of a technique of communication referred to as “Hint and Hope.” One caregiver knows something is wrong but for many reasons related to role definitions and power differentials, cannot effectively communicate his or her concerns to the medical team. In 2000, the Institute of Medicine (IOM) urged health care organizations to train in teams those who are expected to work in teams. Members of healthcare teams are usually trained in separate disciplines,
may not appreciate each other’s strengths, and may not have been trained together on new or well established technology.
While the 58 perinatal events represent just 3.5% of the total number of Level 1 adverse events reported since March 2004 (58/1650), the effects are devastating. Of the reported events, 80% of the neonatal events were fatal (37/46). All but two of these fatalities occurred to full-term neo-nates (38 to 41 weeks). 44% of the surviving infants suffered permanent anoxic injury (4/9). 83% of the maternal adverse events were fatal (10/12), and both mother and baby died in two of the reported adverse events. Other injuries in-cluded broken bones and emergency hysterectomies. The emotional impact on families (and staff) affected by these events is profound, while the financial loss for hospitals can force the closure of obstetric services.
A look at the 11 birth events reported since Janu-ary 1, 2011, shows that there were three post-partum maternal deaths, and eight Level 1 events involving neonates, of which six were fatal. Two infants had to be transferred emergently to a higher level of care, and one child spent 10 days in the neonatal ICU with a metabolic derangement and fractured femur. All of these events were preventable. Communication problems be-tween providers are a known cause of adverse events, and this seems especially relevant to peri-natal events. In most deliveries, there is one physician and one or more nurses literally behind closed doors on secure units. The isolation involved tends to magnify both the unspoken as sumptions held by staff and any miscommunication between staff.
One of the incidents is described below:
A 30 year-old woman presented to the hospital in labor two hours after her membranes ruptured. The full-term fetus was face up with his arm in the vagina. The mother continued in labor for 24 hours at which time the MD attempted a vacuum assisted delivery, with three contractions over 5 minutes. The fetal heart rate dropped precipitously with the last attempt and the decision was made to do an emergency c-section. Delivery was accomplished within 20 minutes but the infant could not be resuscitated. The subsequent autopsy showed no abnormalities.
The Labor and Delivery (L&D) staff and physicians had participated in TeamSTEPPS training but failed to implement the program’s principles. The OB nurses were very concerned about the fetal heart rate from the first day of admission but failed to activate the OB rapid response team, failed to alert the charge nurse, and failed to initiate the chain of command. While the hospital set the expectation for completing TeamSTEPPS, there was no follow up after training to ensure that everyone understood it and its effective use. The MD’s clinical decision making was handled in peer review.||5/11/2020 2:15:52 AM||capteur ultrasonore, électrode de cuir chevelu lésion ou décès néonatal imprévu, décès maternel, lésion causée par l'anoxie, transfert du patient, communication, travail d'équipe ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||Procedure Associated Conditions;Patient Safety Incident|
|Balancing Family Bonding with Newborn Safety||18093||3350||9/1/2014 6:00:00 AM||Pediatric||United States of America||Pennsylvania Patient Safety Authority (USA)||This alert discusses the patient safety incidents of newborn accidental injuries in the care of family members soon after a hospital birth.
Hospitals face a challenge to support bonding of newborns with their families by encouraging breastfeeding, cuddling, holding, and touching while ensuring newborn safety. Analysis of reports submitted to the Pennsylvania Patient Safety Authority from July 2004 to 2013 showed there were 288 newborn events.
Risk reduction strategies are shared in the alert and focus on implementing a falls prevention intervention, providing a safe sleeping environment, providing education for families on newborn safety that includes falls, and implementing a postfall huddle to examine why the fall occurred and what could be done to prevent future falls. Several of the strategies are included in the “Recommendations” section of this alert. ||5/11/2020 2:17:11 AM||narcotics/opiates, IV, transdermal, and oral chutes, allaitement, fatigue, chute, choc, sans réaction, sensibilisation de la famille, éducation, indicateur de chute, incubateur ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Data Snapshot: Maternal Serious Events||18377||3678||12/1/2016 7:00:00 AM||Obstetrics & Gynecology||United States of America||Pennsylvania Patient Safety Authority (USA)||This alert discusses patient safety incidents of 537 maternal events collected over a 5 year period of January 1, 2011 to December 31, 2015. The top five event categories in order of frequency were (1) unanticipated blood transfusion, (2) laceration of the birth canal, (3) unplanned transfer to the intensive care unit, (4) postpartum hemorrhage, and (5) bladder injuries. These categories were not necessarily independent (e.g., a patient may have required an unanticipated blood transfusion and an unplanned transfer to the intensive care unit). Of the 537 events analyzed, 11 (2.0%) resulted in death. Patient stories of each category are provided in the alert.||5/11/2020 2:18:42 AM||placenta, césarienne, hystérectomie, transfusion sanguine, lacération, filière pelvigénitale, transfert imprévu vers l'unité de soins intensifs, hémorragie postpartum, vessie ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False|
|Preventing infant death and injury during delivery||17597||JC14||7/1/2004 6:00:00 AM||Care Management||United States of America||The Joint Commission (USA)||"The overall goal for labour and delivery units is for a healthy and safe birth for the mother and infant. However, there have been patient safety incidents reported where tragedy occurs and the newborn dies. Contributing factors related to perinatal mortality include absence of early and regular prenatal care for the mother, maternal age, previous cesarean section, diabetes, substance abuse, non-reassuring fetal status, placental abruption, ruptured uterus, and breech presentation. This Sentinel Event Alert provides information about identified root causes as well as actions to reduce risk in perinatal mortality."||7/7/2015 8:47:40 AM||Événements liés à la gestion des soins ||https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspx||False||General Patient Safety;Patient Safety Incident|