American Journal of Obstetrics & Gynecology
Volume 200, Issue 5 , Pages 492.e1-492.e8 , May 2009

Impact of a comprehensive patient safety strategy on obstetric adverse events

Presented at the 28th Annual Meeting of the Society for Maternal–Fetal Medicine, Dallas, TX, Jan. 28-Feb. 2, 2008.

  • Christian M. Pettker, MD

      Affiliations

    • Department of Obstetrics, Gynecology, and Reproductive Science, Yale University School of Medicine, New Haven, CT
    • Corresponding Author InformationCorrespondence: Christian M. Pettker, MD, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, 333 Cedar St., PO Box 208063, New Haven, CT 06520-8063
    • ,
  • Stephen F. Thung, MD

      Affiliations

    • Department of Obstetrics, Gynecology, and Reproductive Science, Yale University School of Medicine, New Haven, CT
    • ,
  • Errol R. Norwitz, MD, PhD

      Affiliations

    • Department of Obstetrics, Gynecology, and Reproductive Science, Yale University School of Medicine, New Haven, CT
    • ,
  • Catalin S. Buhimschi, MD

      Affiliations

    • Department of Obstetrics, Gynecology, and Reproductive Science, Yale University School of Medicine, New Haven, CT
    • ,
  • Cheryl A. Raab, RNC

      Affiliations

    • Yale–New Haven Hospital, New Haven, CT
    • ,
  • Joshua A. Copel, MD

      Affiliations

    • Department of Obstetrics, Gynecology, and Reproductive Science, Yale University School of Medicine, New Haven, CT
    • ,
  • Edward Kuczynski, MA

      Affiliations

    • Department of Obstetrics, Gynecology, and Reproductive Science, Yale University School of Medicine, New Haven, CT
    • ,
  • Charles J. Lockwood, MD

      Affiliations

    • Department of Obstetrics, Gynecology, and Reproductive Science, Yale University School of Medicine, New Haven, CT
    • ,
  • Edmund F. Funai, MD

      Affiliations

    • Department of Obstetrics, Gynecology, and Reproductive Science, Yale University School of Medicine, New Haven, CT

Received 27 September 2008 ,Revised 14 November 2008 ,Accepted 19 January 2009.

References 

  1. Kohn L, Corrigan J, Donaldson M. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000;
  2. Williams SC, Schmaltz SP, Morton DJ, Koss RG, Loeb JM. Quality of care in US hospitals as reflected by standardized measures, 2002-2004. N Engl J Med. 2005;353:255–264
  3. Berenholtz SM, Pronovost PJ. Monitoring patient safety. Crit Care Clin. 2007;23:659–673
  4. Bion JF, Heffner JE. Challenges in the care of the acutely ill. Lancet. 2004;363:970–977
  5. DeFrances C, Cullen K, Kozak L. National hospital discharge survey: 2005 annual summary with detailed diagnosis and procedure data; National Center for Health Statistics. Vital Health Stat 13. 2007;165:1–209
  6. Simpson KR, Knox GE. Adverse perinatal outcomes: recognizing, understanding and preventing common accidents. AWHONN Lifelines. 2003;7:224–235
  7. Erzberger C, Prein G. Triangulation: validity and empirically based hypothesis construction. Quality and Quantity. 1997;31:141–154
  8. Farmer T, Robinson K, Elliott SJ, Eyles J. Developing and implementing a triangulation protocol for qualitative health research. Qual Health Res. 2006;16:377–394
  9. Cohen WR, Schifrin BS. Medical negligence lawsuits relating to labor and delivery. Clin Perinatol. 2007;34:345–360
  10. Simpson KR, Knox GE. Obstetrical accidents involving intravenous magnesium sulfate: recommendations to promote patient safety. MCN Am J Matern Child Nurs. 2004;29:161–171
  11. Grunebaum A. Error reduction and quality assurance in obstetrics. Clin Perinatol. 2007;34:489–502
  12. Will SB, Hennicke KP, Jacobs LS, O'Neill LM, Raab CA. The perinatal patient safety nurse: a new role to promote safe care for mothers and babies. J Obstet Gynecol Neonatal Nurs. 2006;35:417–423
  13. Sexton JB, Helmreich RL, Neilands TB, et al. The safety attitudes questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res. 2006;6:44
  14. Sexton JB, Holzmueller CG, Pronovost PJ, et al. Variation in caregiver perceptions of teamwork climate in labor and delivery units. J Perinatol. 2006;26:463–470
  15. Helmreich RL, Merritt AC, Wilhelm JA. The evolution of crew resource management training in commercial aviation. Int J Aviat Psychol. 1999;9:19–32
  16. Nielsen PE, Goldman MB, Mann S, et al. Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial. Obstet Gynecol. 2007;109:48–55
  17. Grogan EL, Stiles RA, France DJ, et al. The impact of aviation-based teamwork training on the attitudes of health-care professionals. J Am Coll Surg. 2004;199:843–848
  18. Ellis D, Crofts JF, Hunt LP, Read M, Fox R, James M. Hospital, simulation center, and teamwork training for eclampsia management: a randomized controlled trial. Obstet Gynecol. 2008;111:723–731
  19. Crofts JF, Ellis D, Draycott TJ, Winter C, Hunt LP, Akande VA. Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomized controlled trial of local hospital, simulation center and teamwork training. BJOG. 2007;114:1534–1541
  20. Jones PE, Roelofsma PH. The potential for social contextual and group biases in team decision-making: biases, conditions and psychological mechanisms. Ergonomics. 2000;43:1129–1152
  21. Paris CR, Salas E, Cannon-Bowers JA. Teamwork in multi-person systems: a review and analysis. Ergonomics. 2000;43:1052–1075
  22. Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf. 2006;32:167–175
  23. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13(Suppl1):i85–i90
  24. Macready N. Two-challenge rule averts errors, improves safety. OR Manager. 1999;15:12
  25. Alonso A, Baker D, Holtzman A, et al. Reducing medical error in the military health system: how can team training help?. Hum Resource Manage Rev. 2006;16:396–415
  26. Parer JT. Electronic fetal heart rate monitoring: research guidelines for interpretation; National Institute of Child Health and Human Development research planning workshop. Am J Obstet Gynecol. 1997;177:1385–1390
  27. Brucker MC, Jones M, Weekly S. EFM case book. Chicago: Center for Certification Preparation and Review; 1999;
  28. Brucker MC, Jones M, Weekly S. EFM case book II. Chicago: Center for Certification Preparation and Review; 2002;
  29. Mann S, Pratt S, Gluck P, et al. Assessing quality in obstetrical care: development of standardized measures. Jt Comm J Qual Patient Saf. 2006;32:497–505
  30. Cherouny P, Federico F, Haraden C, Leavitt Gullo S, Resar R. Idealized design of perinatal care (IHI innovation series). Cambridge, MA: Institute for Healthcare Improvement; 2005;
  31. Forster AJ, Fung I, Caughey S, et al. Adverse events detected by clinical surveillance on an obstetric service. Obstet Gynecol. 2006;108:1073–1083
  32. Berwick D. The science of improvement. JAMA. 2008;299:1182–1184
  33. Nicholson JM, Parry S, Caughey AB, Rosen S, Keen A, Macones GA. The impact of the active management of risk in pregnancy at term on birth outcomes: a randomized clinical trial. Am J Obstet Gynecol. 2008;198:511.e1–511.e15
  34. American College of Obstetricians and Gynecologists. Shoulder dystocia: ACOG practice bulletin No. 40. Obstet Gynecol. 2002;100:1045–1050
  35. Martin J, Hamilton B, Sutton P. Births: final data for 2005; national vital statistics reports. Hyattsville, MD: National Center for Health Statistics; 2007;Vol 56
  36. Chervenak JL. Overview of professional liability. Clin Perinatol. 2007;34:227–232
  37. Murthy K, Grobman WA, Lee TA, Holl JL. Association between rising professional liability insurance premiums and primary cesarean delivery rates. Obstet Gynecol. 2007;110:1264–1269
  38. Barbieri RL. Professional liability payments in obstetrics and gynecology. Obstet Gynecol. 2006;107:578–581

 MCIC Vermont, Inc (New York, NY) provided partial financial support for this project as a quality assurance activity.

 Cite this article as: Pettker CM, Thung SF, Norwitz ER, et al. Impact of a comprehensive patient safety strategy on obstetric adverse events. Am J Obstet Gynecol 2009;200:492.e1-492.e8.

PII: S0002-9378(09)00092-1

doi: 10.1016/j.ajog.2009.01.022

American Journal of Obstetrics & Gynecology
Volume 200, Issue 5 , Pages 492.e1-492.e8 , May 2009

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