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Keywords:

  • perinatal safety;
  • debriefing

Poster Presentation

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  2. Poster Presentation

Purpose of the Program

A convergence of events, including 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.

Proposed Change

The Joint Commission has published Sentinel Event Alerts for preventing infant and 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 her patient.

Implementation, Outcomes, and Evaluation

We studied the science around perinatal safety and went to work to put the principles into place on our unit. 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 members advocate when needed and activate an effective chain of command? We found the answers to these questions were 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. We had a group for fetal monitoring, which decided to teach a course jointly with the providers and staff utilizing the new Eunice Kennedy Shriver, National Institute of Child Health & Human Development language. We had a group who worked on briefings and debriefings. We originally had resistance on debriefing, but it has ended up being a favorite tool. We brought the comments from the debriefings to the Perinatal Committee. We have seen our malpractice suits decrease in the past 5 years. This year our hospital's liability premium was cut by more than $375,000.

Implications for Nursing Practice

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