Each year, approximately 10,000 women are seen and 4,300 babies are delivered at Wesson Women’s Hospital. Serious adverse events that may occur during labor and delivery can impose a heavy physical, psychological, and financial toll on families, providers, and the community. Some of those events include maternal death or serious disability associated with labor or delivery in a low-risk pregnancy, object left in patient after surgery, infant discharged to the wrong person, and death or serious disability associated with failure to identify and treat hyperbilirubinemia, a blood abnormality, in newborns.
Focus on eliminating serious adverse events was reaffirmed in 2005 when BMC started work with the Institute for Healthcare Improvement’s (IHI) Innovative Perinatal Community (now known as the IMPACT Perinatal Improvement Community). In April 2008, the work transitioned to the Premier Perinatal Initiative, and BMC along with 15 other hospitals across the country maintained focus on the improvement of patient safety in the perinatal community.
Baystate Medical Center
BMC has been working to develop the safest environment possible for care of mothers and infants through implementation of many evidence-based practices along with the development of a culture where open, non-punitive error reporting is encouraged. Over the past several years, there have been major practice interventions that have led to significant decreases in birth/neonatal traumas and maternal events.
- Women’s Value Stream Analysis (VSA) LEAN projects undertaken for:
- Providing "Perfect Postpartum Care"
- Eliminating elective deliveries less than 39 weeks gestation; since 2008 our rate has decreased by 98%
- Eliminating elective deliveries of all first time mothers less than 41 weeks gestation, and
- Total induction rate reduced to < 16%.
- Consent specific for administration of oxytocin implemented.
- Monthly high fidelity simulation training--this includes multidisciplinary teams with participation form the newborn and anesthesia departments when appropriate.
- Mandatory Team STEPPS training for all obstetric staff, including refresher courses as needed. This program highlights effective communication strategies necessary for a culture that fosters safety for both the patient and the provider.
- Infant abduction drills conducted semi-annually.
- Required Shoulder Dystocia Management and Electronic Fetal Monitoring Competency Based Learning modules (on CD) for all nurses, midwives and physicians as part of the skills validation and credentialing process.
- PeriBirth (medically intelligent electronic medical record for obstetrics) updates include meaningful use certification measures, patient status order entry, and postpartum depression screening.
- Interdisciplinary Perioperative Committee reviews practices, policies, and procedures relevant to perioperative care.
- Handover at bedside (RN knowledge transfer) implemented.
- Purposeful bedside rounds implemented.
- TDAP vaccine administration implemented for all postpartum mothers--information given to families regarding the importance family immunization to protect the infant. Our monthly administration rate continues to be greater than 80%.
- Close review of maternal transfusion cases continues with no specific practice trends apparent; Grand Rounds conducted regarding management of hemorrhage and current performance meets Premier benchmark.
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