A convergence of events – published literature on causation of adverse events in maternal newborn care, claims analysis, a Joint Commission Sentinel Event Alert, and a lawsuit – galvanized our resolve at Hunterdon Medical Center to discover and address all issues that compromise the safety of our patients.  A wise person once said: “There is always more to the story.”  We have found that to be the case. 

Framework for the talk: 

The Joint Commission has published Sentinel Event Alerts, for preventing infant harm, and now for preventing maternal harm.  Most of the events that harm our patients are preventable.  Often there is an experienced nurse, who is concerned, but fails to rescue their patient.  We studied the science around perinatal safety, and went to work to put the principles into place on our unit.

Implications for practice:  

We began to ask what our chief medical officer referred to as the “wicked questions”.  What keeps staff and providers up at night about the way we provide care.  Where are near misses happening?  Do folks feel free to speak up?  Are we getting incident reports?  Do staff advocate when needed & activate an effective ‘Chain of Command’?

We found the answer to these questions, was not always easy to hear.  We hired outside consultants to do team training with all members of our team.

We formed interdisciplinary teams.  The first worked on policies; induction of labor (we put in place the IHI bundles) and pitocin, as well as others.

We had a group for fetal monitoring, who decided to teach a course jointly with the providers and staff utilizing the new NICHD language.

We had a group who worked on Briefings and on Debriefings.  We originally had  resistance on debriefing, but it has ended up being a favorite tool:

n      What could we have done better?

n      Did we have everything we needed?

n      Anything else?

We bring the comments from the debriefings to Perinatal Committee.

We have seen our malpractice suits go from as many as 7 one very bad year, to not one in 5 years.  This year our hospital’s liability premium was cut by over 375,000 dollars.  

Implications for practice:  

We have been able to sustain true process changes.  We have built a team, that is serving our moms and babies well, and feel the pride that comes from a hard won battle that is well worth the cost.