Recommendations made in Sentinel Event Alert
It’s without question one of the most tragic things that can occur at any hospital: An infant’s death during delivery.
According to a recent Sentinel Event Alert, nearly 75% of hospitals in the Joint Commission on Accreditation of Healthcare Organizations’ health care errors database cited communication breakdowns as a major reason for these devastating events. According to the alert, the hospitals identified problems including lack of teamwork and an atmosphere that discourages team members from speaking up to ask for clarification.
Staff competency and training, inadequate fetal monitoring, and unavailability of monitoring equipment and/or drugs also are listed as root causes. The Sentinel Event Alert recommends the following:
- conducting formal team training sessions for the obstetrical/perinatal team;
- using care guidelines established by the American Academy of Pediatrics, the American College of Obstetricians, and Gynecologists, and the Association of Women’s Health, Obstetric, and Neonatal Nurses;
- developing clear procedures for fetal monitoring of potential high-risk patients;
- taking steps to ensure key personnel are available for emergency interventions;
- making certain that neonatal resuscitation areas are fully equipped and functioning.
"As with all Sentinel Event Alerts, there is good evidence-based information," says Angie King, BSN, CPHQ, quality management director at Tift Regional Medical Center in Tifton, GA. "My concern is that during this time of medical malpractice crisis, plaintiff’s attorneys will use this as a hammer."
Infant death and injury during delivery does not automatically constitute fault on the caregivers’ part, yet these occurrences are very difficult to defend in a malpractice lawsuit because a jury is predisposed to feel sympathy when it comes to infants, King notes.
"I have seen plaintiff’s attorneys use the Joint Commission’s Sentinel Event Alerts to set a standard," she says. "They will use the recommendations not as a point of causation, but as a symbol of hospitals not following the standard of care."
King points to the alert’s recommendation for conducting team training to improve communication. "If that is not documented, it could be used as a cause of poor communication. The onus is on the hospitals to closely review the entire alert, implement as much as possible, and document the implementation," she adds.
After King received the alert, she immediately developed an action plan by working directly with the organization’s chief of obstetrics and nursing leadership. A task force was formed comprised of obstetrics nurses and managers, education personnel, and obstetricians who will review both the recommendations and the organization’s risk reduction strategies.
"Action plans and timelines are assigned with our task force," King notes. "Special team training will be held for the current staff and then added to unit-specific orientation."
The biggest take-home message from the alert is the urgent need for better communication among caregivers, urges Fay A. Rozovsky, JD, MPH, assistant vice president and manager of the risk management health care group at Chubb Specialty Insurance in Simsbury, CT.
"You can have the best systems in place, but if people don’t communicate effectively, accurately, and in a timely manner, then it is all for naught," she says.
She gives the example of a nurse who says that the reading on a fetal monitoring strip "looks OK."
"To me, that might mean we should be watching and checking back in a couple minutes; and to someone else, it may mean that everything is fine and I can move on to the next patient," adds Rozovsky.
All team members must have the same understanding as to the meaning of the terminology used, or dangerous misunderstandings may occur, she says, noting that this is difficult when working with residents or agency personnel.
Rozovsky suggests using consistent terminology and avoiding use of terms that can be interpreted a variety of ways. Another solution is to encourage staff to repeat back what they are hearing, which is done routinely in the food, law enforcement, and aviation industries.
"If they can do that, why can’t we?" she asks. "It’s not enough to say, I understand,’ — the caregiver should repeat back what they’ve heard."
Rozovsky also recommends encouraging staff to speak clearly, using a consistent chain of command system with a quick response time when communication problems arise, and using checklists for communicating with patients.
"As a risk management professional, it’s astonishing to see how communications play such a major role in loss prevention and yet persists as a major issue," Rozovsky says.
"This is not something that requires a capital expenditure, but it goes right to the core of patient safety. If people would learn how and when to communicate with one another, a lot of the problems that we see might not make it to the light of day," she adds.
[For more information on preventing infant deaths, contact:
• Angie King, BSN, CPHQ, Quality Management Director, Tift Regional Medical Center, 901 E. 18th St., Tifton, GA 31794. Phone: (229) 386-6119. Fax: (229) 556-6390. E-mail: [email protected].
• Fay A. Rozovsky, JD, MPH, Assistant Vice President, Manager, Risk Management Health Care Group, Chubb Specialty Insurance, 82 Hopmeadow St., Simsbury, CT 06070-7683. Phone: (860) 408-2322. Fax: (860) 408-2334. E-mail: [email protected].]
Its without question one of the most tragic things that can occur at any hospital: An infants death during delivery.
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