Emerging Trends in Perinatal Quality and Risk With Recommendations for Patient Safety

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Excerpt

As a consultant in patient safety and quality for hospitals and healthcare systems in the United States, there is opportunity to review cases and reports of harm while being aware that a nearly identical case just occurred in another hospital across the country, having reviewed that as well. Access to reports of accidents before they begin to be noted in numbers and frequency to be published in the literature allows a unique perceptive. Hospitals and healthcare systems are generally not keen to report single adverse events or series of adverse events in the literature because of liability concerns. This is unfortunate because it can be very useful for clinicians to be made aware of possible risks based on others' experiences before an injury happens.
In maternity and newborn care, the general health and young age of our patients often preclude an adverse outcome when conditions are such that the best care was not provided. This rare occurrence leads to a false assumption that the adverse event was a fluke rather than reflective of an underlying need to comprehensively evaluate routine operations and modify practice. Near misses are often not appreciated for their value in the ability to carefully review care and interdisciplinary communications that were involved in an open honest process without the anxiety and tension surrounding a patient injury. Hospitals, including those part of large health systems, often do not have robust reporting strategies to be able to identify trends in a timely manner and make a determination to change. Reporting criteria and systems vary widely among hospitals and are influenced by the safety culture on the unit. In a poor safety culture where there is fear of retribution and retaliation, no amount of effort, including lists of requirements and leadership requests, is going to generate reports that can lead to action for improvement. Critical data that could be used to improve care and minimize risk of preventable patient harm are frequently fragmented, unreported, and not fully understood. Transparency and timely sharing of these types of data within hospital systems can be vital in offering resources to support collective efforts to promote safe care.

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