As the perinatal patient safety nurse at Yale-New Haven Hospital in Connecticut, Cheryl A. Raab, RNC-INP, BSN, C-EFM, spends her days training, educating, collecting and assessing data all with the goal of making the labor and delivery department safer for mothers and infants. She constantly asks physicians, nurses and support staff: How are we going to harm the next patient we see, and what can we do to keep that from happening?
Its a question being echoed at a growing number of U.S. hospitals that have implemented obstetric patient safety programs a bundle of interventions that include clinical education and training, standardized procedures and hiring dedicated staff such as patient safety nurses and hospitalists physicians and nurse midwives for off-hours deliveries. Some hospitals that use these programs are reporting the lowest rates of adverse and potentially harmful incidents theyve ever had.
Its a very important movement that has the potential to really benefit women and families, says Audrey Lyndon, RNC, PhD, CNS-BC, assistant professor and director of the perinatal clinical nurse specialist program at the University of California, San Francisco School of Nursing, of the trend toward implementing obstetric patient safety programs in hospitals. I think we are at the point where there is an increasing body of evidence that suggests we should be doing this. But were still learning.
The maternal death rate in the U.S., after dropping dramatically from 1915 to 1970, has remained virtually unchanged in the past 25 years, according to the U.S. Department of Health and Human Services. The U.S. rate exceeds that of more than 40 other countries, and some evidence shows an increase in reported severe pregnancy complications that can cause death. Traumatic birth injuries occur in about 7.4 cases per 1,000 live births in the U.S., according to the federal Agency for Healthcare Research and Quality. Research has identified a number of preventable errors that can lead to high-risk situations, including failure to recognize fetal distress, failure to start an emergency C-section in time, inappropriate use of oxytocin, inappropriate use of vacuum devices and forceps, poor communication among caregivers and failure to use the chain of command during a clinical disagreement.
More than half of medical malpractice claims against physicians are obstetric. Although claims against nurse midwives are much fewer than those against physicians (physicians in all areas of care are sued far more often than nurses), cumulative payouts for obstetrics-related claims against nurses from 1990 to 2006 were higher than for any other malpractice reason, according to the 2006 National Practitioner Data Bank Annual Report.
Obstetrics traditionally has one of the highest risks for medical lawsuits, in part because things can go wrong quickly, and because women entering a hospital to deliver a baby have high expectations, says Diana J. Behling, RN, BSN, MJ, manager of the OB Right patient safety program at Sentara Healthcare, based in Norfolk, Va. Everyone expects to have the Gerber baby. But sometimes, she says, things go wrong that are natural, and sometimes things go wrong that are hospital-caused.
Not all adverse events during childbirth are preventable, obstetric experts say. But recent research indicates many potential hazards such as maternal bleeding, fetal distress or a sudden spike in maternal blood pressure can be handled with greatly reduced risks when hospitals adopt safety programs that promote critical thinking, advance preparation, communication and a strong policy of safety first, say nurses involved with the programs.
A 2004 study by The Joint Commission reported communication issues topped the list of root causes of cases of perinatal deaths, occurring in 72 % of all cases. Spurred in part by an incident in 2000 that resulted in an infant death and the mother spending 18 days in intensive care, Beth Israel Deaconess Medical Center in Massachusetts became a pioneer for patient safety programs, partnering with the Department of Defense on a pilot project to improve teamwork and communication in its obstetrics departments, based on similar training in the aviation industry.
Our biggest initiative in patient safety is team training and enhancing contact between the providers, says Penny Greenberg, RN, MS, executive vice president and CNO at Beth Israel Deaconess Hospital Needham. Its about how can we work better as a team, she says.
Strengthening the Core
Physicians and nurses are taught the core concepts of teamwork, including that all providers are aware of every patients care plan and of who is covering each patient; all staff participate in team meetings and other group communication efforts; and conflicts among team members about patient care are managed constructively and respectfully.
Greenberg, who also works per diem in L&D at Needham, says she has seen great improvement in communication since the training program began. In the past, she says, she took care of her own patients, but unless she worked as a charge nurse, I really wouldnt know what was going on in the whole unit. Now, she says, thanks to team meetings and regular communication, she knows which patients on the unit might have problems or special needs, how they are progressing and who might need extra help. The teamwork and camaraderie that had always seemed solid in the past, she says, is better now.
An important aspect of improving communication is creating common language so all clinicians understand what the others are saying when they describe a fetal heart rate or an urgent need for anesthesia, nurse safety experts say. This can include briefing techniques such as SBAR situation, background, assessment, recommendation and listening for key words such as concerned, uncomfortable, or scared. For instance, after realizing anesthesiologists could misunderstand the immediacy of requests for anesthesia during C-sections, Behlings team switched to standardized language familiar to all care providers. For instance, a Code 1 means an emergency, such as a uterine rupture or cord prolapse, that takes precedence over other unit activities. A Code 4, the lowest level, means the patient usually is scheduled in advance or can be postponed for another day, such as a breech presentation when the mother is not in labor or under stress.
Obstetric patient safety programs also standardize protocols, so nurses dont have to remember one physician does a procedure a certain way, and another prefers to do it differently. Physicians rail against the idea of cookbook medicine at first, Behling says, but after seeing data showing how standardization helps reduce errors, most embrace it. Some of the most skeptical often become the programs biggest supporters, she says.
In 2004, Yale-New Haven partnered with its malpractice insurer, MCIC Vermont Inc., to roll out an obstetrics patient safety program in two years. The hospital standardized protocols, hired Raab and a hospitalist, created a patient-safety committee and required training in team communication skills and fetal heart monitoring interpretation. The program significantly reduced adverse outcomes and increased perceptions of safety and teamwork among the staff, according to a report on the impact of the program, published in the American Journal of Obstetrics and Gynecology in May 2009.
As her departments patient safety nurse, Raabs initial responsibility is to develop ways to evaluate clinical care and outcomes, looking for weaknesses that might compromise patient safety. She also creates and runs education programs, collects and assesses data, manages an anonymous reporting system, investigates errors and near-misses and presents her findings to the patient safety committee. Raab also holds teamwork training sessions, reviews protocols, and organizes drills that simulate emergency situations, such as maternal hemorrhaging or a prolapsed cord, always soliciting feedback from the labor and delivery staff.
Part of the reason for the programs success, she says, is that it involves every person on the unit and all are encouraged to offer ideas on how to improve patient safety. It doesnt take a licensed professional to come up with the best ideas, she says. Nonclinicians, such as transport workers or nursing assistants, may observe patterns or situations on the unit that clinicians havent noticed.
Sentara Healthcare started its patient safety program in two hospitals in 2005, says Behling, with two objectives: the programs components would be based on solid research and it would put patient safety above all other concerns, including providers time constraints. Using those provisions, the patient safety team adopted a number of goals, including reducing vaginal and C-section elective deliveries; standardizing clinical protocols, including the language clinicians use; creating evidence-based protocols for certain procedures, such as oxytocin use; and creating a committee to review data from the L&D departments sentinel events and near misses.
We are particularly interested in those [events] that dont harm patients, Behling says. Part of the committees work, she says, is to see what prevents a situation from becoming serious so it eventually can be incorporated into hospital protocols, if evidence shows it improves patient safety.
The OB Right program, which has expanded to all of Sentaras L&D units, includes Web-based education programs, emergency simulations and a strong communication component, Behling says. The health systems elective deliveries and birth trauma rates are lower than the national average, and malpractice rates have decreased. Today I can say were successful, but the work is never done, she says.
The greatest challenge for any patient safety program is keeping it going, say nurses who work with the programs. The training and initial results are exciting, but after a while the numbers start to level off and people can become complacent. You can lull yourself into a sense of security, Behling says. In a safety program, youre working against human nature because human nature is not to change.
Reviews, repeated trainings, regular team meetings, and good leaders and managers visibly committed to patient safety help keep up the momentum. Raab says one of the most important aspects of her job right now is to keep safety always foremost in the minds of the obstetrics team. The only concern of my day is safety, she says. This is my job, 24/7.