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In 2004 The Joint Commission (TJC) issued Sentinel Event Alert # 30 which focused on preventing infant death and injury during delivery. TJC examined 47 cases and found that communication failure accounted for 72% of the identified root causes. Other root causes identified were 55% organizational culture barriers; 47% staff competency; 40% orientation and training process; and 34% inadequate fetal monitoring. In addition, frequent allegations in obstetric (OB) litigation cases include: inadequacy  of staff training and experience in emergency management; failure to recognize/respond to non-reassuring fetal status; failure to do a timely delivery; failure to conduct a proper resuscitation; failure to prevent and manage shoulder dystocia; negligence by a vacuum or forceps; and improper use of oxytocin.

As a large health care system in north Texas we have a diverse patient and staff/provider population. Eleven entities provide obstetric services to small rural and large urban communities. Nursing staff float from small to large facilities and we saw the need to standardize recognition and response to management of OB emergencies within our system.  We also recognized that smaller facilities could benefit from the educators and resources available at the larger hospitals.  In addition, it was clear there was a need to have all staff nurses trained to interpret fetal monitor strips using the same language and to have physicians using this language as well. The program started with nurses and physicians collaborating to create a system wide guideline for training of staff and recommended management of emergencies. After the guideline was approved and implemented, we received funding from the hospital foundations to purchase patient simulators to enhance the learning experience and to elevate the skill of the staff.

The goal of this project was to spread best practices and lessons learned across the system. The project was launched in the first quarter of 2008. The drills are video taped and participants are debriefed. A summary of the debriefing and lessons learned are then shared at the entity level at the appropriate safety/quality committees and at the system level. There have been eye opening lessons shared such as: determining that not all operating rooms were equipped with code blue pull stations; dose amounts and routes for Cytotec for post partum hemorrhage were inconsistent with evidenced based literature recommendations; nursing staff were surprised at how much more difficult it was to compress and ventilate the simulator than it was the CPR chest; logistics of getting from one floor to another when the OR is on a different floor; and the need to educate supporting departments about mock codes and the simulator.