Multidisciplinary Severe Maternal Morbidity Reviews Can Teach the Clinical Learning Environment Review Focus Areas of Patient Safety and Quality

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PURPOSE:To describe a resident focused multidisciplinary severe maternal morbidity (SMM) review program.BACKGROUND:The Joint Commission defined SMM as peri-partum blood transfusion of 4 units or admission to ICU and recommends multidisciplinary reviews to determine opportunities for improvement in careMETHODS:An ongoing process detects cases of SMM with root-cause-analysis performed if case qualifies as a sentinel event. Data is extract and presented quarterly to, a multidisciplinary committee to determine contributory factors, opportunities to alter outcome, best practices and recommendations.RESULTS:Forty-five SMM cases were reviewed from 1/15 to 6/17 by residents 67%, fellows 9%, nurses 7%, and MFM faculty 17%. Opportunities to alter care were determined to be strong in 9% and possible in 62%. System/provider could alter outcome in 53% while the patient could have altered outcome in 33% of cases. Outcomes could have been altered by contraception/sterilization in 13%, patient compliance 11%, early prenatal care 20%, referral/consultations 9%, improved documentation 7%, early recognition 33%, team communication 4% and management 31%. Good practices recognized included multidisciplinary teamwork/communication 60%, evidence-based response 36%, timely recognition 24%, documentation 20%, quality obstetric care 22%, timely referral 13%, expertise care 9%, and patient-centered-care 7%. Strong opportunity to alter outcome was present with hypertensive crisis (P=.026). Significant opportunities to alter outcomes were: preterm SMM cases by contraception/sterilization (P=.036); patient compliance in Medicaid insured (P=.01) and younger women (P=.04). Transfusions were recognized for the good practice of timely recognition (P=.045).DISCUSSION:Residents' involvement in SMM reviews can determine care improvement opportunities and provide training on safety and quality.

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