• E-mail
• Print
• RSS

Provide team training in perinatal areas to improve communication and cooperation among staff to avoid infant death and injury during birth procedures, the JCAHO advises in its first Sentinel Event Alert since June 2003.

Patient Safety Monitor Alert, July 28, 2004

Want to receive articles like this one in your inbox? Subscribe to Patient Safety Monitor Alert!

The July 21 alert, titled Preventing infant death and injury during delivery, warns about the injuries and fatal errors that can occur during "what should be a joyous, celebratory event."

Although the rate of perinatal mortality in the U.S. declined in 2001 to a rate of 6.9 deaths per 1,000 live births, the JCAHO has received reports of at least 61 cases of perinatal death and 10 cases of permanent disability since 1995.

The root causes of these errors include all of the usual challenges that patient safety officers strive to overcome:

>> Communication breakdowns: More than half of the organizations that have reported perinatal errors and deaths to the JCAHO have cited organizational culture as a barrier to effective communication and teamwork. Hierarchy and intimidation are the main culprits, the JCAHO reports.

>> Failure to function as a team

>> Failure to follow the chain-of-communication

>> Weak staff competencies

>> Poor orientation and training processes

>> Inadequate fetal monitoring

>> Unavailable monitoring equipment and/or medications

>> Credentialing/privileging/supervision issues

>> Staffing shortages/staffing issues

>> Unavailable or tardy physicians

>> Missing or unavailable prenatal information

The JCAHO offers several recommendations to avoid these errors, including better team training and conducting clinical drills and debriefings "to evaluate team performance and identify areas for improvement."

The JCAHO has reviewed 2,552 sentinel events since 1995. Communication, orientation, and patient assessment deficiencies are most often cited as the root causes. The top five sentinel events, according to the JCAHO's most recent statistics, include:

1. Patient suicide: 382 have been reported since 1995, representing 15% of the total events reported

2. Op/post-op complications: 330 have been reported, representing 12.9%

3. Wrong-site surgery: 310, 12.1%

4. Medication errors 291 11.4%

5. Delay in treatment 172, 6.7%

The JCAHO's sentinel event policy requires the accreditor to review "any perinatal death or major permanent loss of function unrelated to a congenital condition in an infant having a birth weight greater than 2,500 grams."

Likewise, the JCAHO expects accredited hospitals to review all of its Sentinel Event Alerts and to "consider implementing" the recommendations that they contain.

Want to receive articles like this one in your inbox? Subscribe to Patient Safety Monitor Alert!

• E-mail to a Colleague
• Print
• RSS
• Archive