Clinical audit, case review, or analysis of adverse events

In the Literature: Physiologic, evidence-based oxytocin protocol reduces tachysystole

As part of a larger program to achieve zero preventable birth injuries, this project’s goal was to avoid tachysystole or appropriately intervene when tachysystole occurred. Tachysystole is defined as more than 5 contractions in 10 minutes, averaged over a 30-minute window, and is often associated with induced or augmented labor.

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Filed in Blueprint, Clinical audit, case review, or analysis of adverse events, Clinical practice guideline/policy change, Educational materials for health professionals, Health professions education, Improved liability system, Performance measurement, Progress, Team building on Tue., Oct 18, 2011

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From the Field: The Safe Motherhood Quilt Project

The Safe Motherhood Quilt Project, originated by midwife Ina May Gaskin, is a national effort developed to draw public attention to the current maternal death rates, as well as to the gross underreporting of maternal deaths in the United States. The Quilt honors American mothers who have died of pregnancy or childbirth related causes since 1982, the last year there was a reduction in maternal mortality.

The goal of the Safe Motherhood Quilt Project is to demand an equivalent system of counting, analyzing, and learning from mistakes made in our maternity care system here, regardless of where babies are born or what caregiver is the birth attendant. Until we do that, doctors, midwives, and nurses in the US will continue to work without a good system of feedback about what is and is not dangerous in maternity care, and preventable maternal deaths will continue to take place.

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Filed in Clinical audit, case review, or analysis of adverse events, Clinical controversies, Community education/outreach, Consumer advocacy or political action, Disparities, Educational materials for health professionals, Health information technology, Improved liability system, Performance measurement, Performance measurement/reporting, Stories from the Field, Team building on Mon., Sep 12, 2011

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From the Field: Eliminating Preventable Perinatal Injuries and Reducing Malpractice Claims and Costs: Creating High Reliability Obstetrics Units

We intend to reduce perinatal harm and decrease malpractice events by eliciting improved compliance in 4 clinical care bundles and implementation of an evidence-based simulation training methodology focused on improving clinical staff’s ability to work in teams. We are measuring our impact through a culture of safety survey and a high reliability survey, various outcomes measures.

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Filed in Blueprint, Care coordination, Clinical audit, case review, or analysis of adverse events, Clinical controversies, Clinical practice guideline/policy change, Decision making and choice, Health professions education, Improved liability system, Performance measurement, Performance measurement/reporting, Risk management/liability reform, Shared decision making, Skills training or drills for health professionals, Strategies, Team building on Mon., Aug 1, 2011

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In the Literature: At Intermountain, process improvement reduces inductions, cesareans, NICU admissions, and costs

As a result of process improvement efforts bolstered by robust information systems, the proportion of all inductions that lacked strong indications for clinical appropriateness fell from 28 percent to less than 2 percent. The project also resulted in decreases in both NICU admissions and cesareans, and Intermountain estimates that the elective induction protocol reduces health care costs in Utah by $50 million per year.

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Filed in Blueprint, Clinical audit, case review, or analysis of adverse events, Clinical controversies, Clinical practice guideline/policy change, Health information technology, Health information technology, In the Literature, Payment reform, Performance measurement, Performance measurement/reporting on Fri., Jul 29, 2011

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From the Field: Postpartum Depression Task Force

The Postpartum Depression Task Force of Monroe County seeks to improve identification and treatment for women with perinatal mood disorders. The Task Force is a coalition of providers from all aspects of maternal-child health, including doctors, nurses, psychiatrists, psychologists, social workers, doulas, childbirth educators, hospital and medical office administrators, and consumers. Measures include attendance at continuing education events; numbers of in-services and outreach events; as well as improved identification and referral systems within the hospital as well as in the community.

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Filed in Care coordination, Clinical audit, case review, or analysis of adverse events, Clinical practice guideline/policy change, Community education/outreach, Educational materials for health professionals, Health professions education, Shared decision making, Staffing/care coordination change, Stories from the Field, Team building on Thu., Jul 14, 2011

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Federal Legislative Action: Maternal Health Accountability Act of 2011

The Maternal Health Accountability Act would provide grants to states for mandatory reporting of pregnancy-related deaths, establishment of a state maternal mortality review committees, and standardization of data collection. It would also support research on “near miss” cases and eliminating disparities in maternal health outcomes.

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Filed in Blueprint, Care coordination, Clinical audit, case review, or analysis of adverse events, Disparities, Federal Legislation, Performance measurement, Performance measurement/reporting on Thu., Apr 21, 2011

From the Field: Obstetrics Clinical Outcomes Assessment Program (OB COAP)

The Obstetrics Clinical Outcomes Assessment Program (OB COAP) is a clinician-led data collection and analysis initiative that uses chart-abstracted data of the variables relating to the management of a pregnant woman who delivers in the state of Washington. Its goal is to ensure that all women in the state of Washington receive the same evidence-based obstetrical care. OB COAP gathers the intrapartum data needed to optimize management of labor and delivery.

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Filed in Blueprint, Clinical audit, case review, or analysis of adverse events, Clinical controversies, Decision making and choice, Disparities, Performance measurement, Performance measurement/reporting, Stories from the Field, Workforce on Wed., Apr 6, 2011

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Federal Legislative Action: Maternal Health Accountability Act of 2011

New legislation introduced in the US House of Representatives would provide grant funding for states to establish Maternal Mortality Review Committees to examine pregnancy-related deaths and to identify ways to reduce maternal mortality. HR 894, the Maternal Health Accountability Act of 2011, would also help to eliminate disparities in health care, risks and outcomes.

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Filed in Clinical audit, case review, or analysis of adverse events, Disparities, Federal Legislation, Performance measurement, Performance measurement/reporting on Mon., Apr 4, 2011

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In the Literature: A comprehensive perinatal patient safety program to reduce preventable adverse outcomes and costs of liability claims

After implementation of this comprehensive patient safety program, birth trauma rates decreased, the number of obstetrical occurrences (specified birth-related event or injury that may lead to a claim) decreased by 65%, and the average costs per obstetrical claim decreased. The number of new claims reported decreased by 48%.

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Filed in Clinical audit, case review, or analysis of adverse events, Clinical practice guideline/policy change, Educational materials for health professionals, Improved liability system, In the Literature, Performance measurement, Performance measurement/reporting, Risk management/liability reform, Staffing/care coordination change, Team building on Sun., Apr 3, 2011

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From the Field: Michigan Health and Hospital Association Keystone: OB

Keystone: OB focuses on preventing elective inductions and elective cesareans before 39 weeks. We are also focused on assuring safe care during labor induction, augmentation, and the second stage of labor. In addition, we provide recommendations on electronic fetal monitoring, and most importantly improving the culture of safety in the unit.

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Filed in Clinical audit, case review, or analysis of adverse events, Clinical controversies, Clinical practice guideline/policy change, Educational materials for health professionals, Performance measurement, Performance measurement/reporting, Stories from the Field, Team building on Thu., Mar 17, 2011

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