Improving Care during a Postpartum Hemorrhage: A Patient Safety Initiative
Version of Record online: 14 JUN 2012
© 2012 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses
Journal of Obstetric, Gynecologic, & Neonatal Nursing
Special Issue: 2012 Convention Proceedings
Volume 41, Issue s1, pages S82–S83, June 2012
How to Cite
Labardee, R. M. and Mitch, R. (2012), Improving Care during a Postpartum Hemorrhage: A Patient Safety Initiative. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 41: S82–S83. doi: 10.1111/j.1552-6909.2012.01361_40.x
- Issue online: 14 JUN 2012
- Version of Record online: 14 JUN 2012
- postpartum hemorrhage;
- process improvement initiative;
- patient safety
Purpose for the Program
According to the American College of Obstetricians and Gynecologists (the College), 140,000 maternal deaths occur each year and approximately 25% of those deaths are due to postpartum hemorrhage. One of the Healthy People 2020 goals is to decrease maternal deaths from 13.3 deaths per 100,000 live births to 11.4 per 100,000 live births. The purpose of our project was to develop a method of obtaining necessary supplies for prompt treatment of a postpartum hemorrhage.
Our plan was to develop a multidisciplinary team to discuss the best approach and supplies needed to promptly manage a postpartum hemorrhage. Our multidisciplinary team consisted of staff nurses, nurse educators, a nurse practitioner, ancillary staff, management, and resident physicians. Current literature and available products were reviewed by the team. The product chosen to best meet our needs was a medical supply cart.
Implementation, Outcomes, and Evaluation
Once a consensus of the team was reached regarding cart style and specific features required, the cart was purchased and assembled with the supplies as identified by the team. The cart was displayed on the postpartum unit for 2 weeks, allowing staff the opportunity to become familiar with the contents. Feedback from staff was encouraged. The team evaluated the feedback and changes to the cart were made. Data regarding the frequency of use of the hemorrhage cart, along with staff feedback are being collected and shared with the multidisciplinary team. Anecdotally, staff state response time to postpartum hemorrhage has decreased significantly. Instead of spending time gathering needed supplies, staff members are able to respond and assist in prompt patient treatment. Ongoing education needs regarding cart contents, layout, and restocking procedures have been identified, and therefore, continual education occurs through one-on-one discussion and weekly newsletters.
Implications for Nursing Practice
Future emergency simulations on our unit will incorporate the use of the postpartum hemorrhage cart. These simulations will not only allow staff to practice their skills in caring for a patient with a postpartum hemorrhage, but also will encourage staff to refamiliarize themselves with the cart contents. Our hope is that future sharing of our experiences with other maternity centers will foster collegiality and improve patient outcomes across the country.