Purpose for the program: In January 2010 The Joint Commission issued a Sentinel Event Alert addressing maternal death prevention. The Center for Disease Control states current trends indicate maternal mortality rates may be increasing. The latest published statistics from 2006 cite 13.3 maternal deaths per 100,000 live births, far from the Healthy People 2010 target of no more than 3.3 deaths per 100,000 live births.  "Near misses" (maternal complications severe enough to endanger a woman's life) have also increased to approximately 34,000 a year.  Analysis of negative outcomes calls for improvement in patient safety.  Education utilizing evidence based practice can be a key in providing quality patient care.

Proposed change: Recognizing the impact and great personal loss, The Memorial Hermann Healthcare System took the initiative in addressing maternal death prevention through an aggressive educational program.  The initial goal was to develop evidence based guidelines for nurses to follow when they identified changes in their patient's condition and to improve communication between the healthcare team. 

Implementation, outcomes and evaluation: A team of perinatal educators developed core content related to three leading causes of maternal death: postpartum hemorrhage, hypertensive disorders and venous thrombotic events.  Pharmacology was covered within each section as it pertained to the disease and treatment.  After collaboration with OB physicians, the content was offered as a system wide mandatory class presented by hospital perinatal educators.  During May and June 2011 approximately 350 Labor and Delivery and Postpartum nurses from four hospitals attended with a 95% compliance.  The remaining hospitals in the system are currently implementing the program.  Evaluations were overwhelmingly positive with many nurses expressing satisfaction with the content, guidelines, case studies, and use of SBAR for communicating with physicians.  Originally it was thought the core content could be taught as three separate one hour offerings but the vast majority of hospitals chose to do one three hour session. This decision actually facilitated both scheduling the classes and tracking of attendees.  Nursing contact hours were provided.  Registration and completion of the course was entered on a system website.

Implications for nursing practice: With education comes empowerment and with evidence based guidelines to support their assessment, nurses can respond quickly to changes in their patient's condition.  The use of SBAR promotes clearer communication between nurse and physician. As a result of this first educational program, physicians and nurses will soon be required to take additonal self study modules aimed at reducing negative maternal outcomes and improving patient safety.

Keywords: Maternal death prevention, perinatal education, patient safety