Pennsylvania's Patient Safety Advisory targets complications during pregnancy and childbirth

Pennsylvania Patient Safety AuthorityDec 17 2009

The complications of pregnancy and childbirth have been targeted in the Pennsylvania Patient Safety Authority's 2009 December Supplementary Patient Safety Advisory. The special issue provides gynecologists, obstetricians, midwives and the entire obstetric team, with strategies to help them prevent the complications based upon real Pennsylvania data.

"Due to the volume of data we have from facilities submitting reports, the Authority is able to target specific physician groups based upon their field of practice," Mike Doering, executive director of the Pennsylvania Patient Safety Authority said. "This issue concentrates on the complications obstetricians, midwives and the entire obstetric team have encountered during labor and delivery within Pennsylvania facilities for the last five years."

The Advisory contains four articles with in-depth discussion on medication errors in labor and delivery, preventing harm to mothers and babies during vacuum-assisted vaginal deliveries, discussion regarding neonatal complications with shoulder dystocia and an overall snapshot of complications that resulted in 256 reports in which the mother was harmed (including 20 deaths) during pregnancy and childbirth.

The titles and descriptions of the articles are as follows:

• Medication Errors in Labor and Delivery: Reducing Maternal and Fetal Harm: Pennsylvania healthcare facilities submitted 2,611 event reports involving medication errors in labor and delivery units between June 2004 and April 2009. Analysis shows that the most common medication error event type associated with this area is dose omission (22.5%), followed by wrong drug (10.7%). Further analysis shows that 46.4% of wrong/dose/overdosage errors and 55.2% of wrong-rate errors involved high-alert medications. Strategies to prevent medication errors and patient harm in the specialty setting include standardizing the dosing and administration protocols as well as standardizing the concentrations and dosing units of drug infusions and adopting a policy that all infusions be administered with an infusion pump.
• Preventing Maternal and Neonatal Harm during Vacuum-Assisted Vaginal Delivery: When women in the second stage of labor fail to progress in the second stage of labor, vacuum extractors have been used to successfully aid delivery. However, the Pennsylvania Patient Safety Authority received 367 reports of problems involving vacuum-assisted delivery from July 2004 through April 2009. Of these reports, 282 (77%) documented some form of injury to the baby or mother. To maximize the success of vacuum extraction procedures and to minimize complications, clinicians must understand both indications and contraindications for this procedure. The article discusses in-depth the important patient safety concepts associated with vacuum-assisted vaginal delivery procedures. A poster and chart review tool are also available for facilities.
• Neonatal Complications: Recognition and Prompt Treatment of Shoulder Dystocia: The Authority has received over 316 reports of babies who experienced getting their shoulder stuck (known as shoulder dystocia) in the birth canal during delivery. In 124 (39%) reports the babies' injuries from the shoulder dystocia included: broken bones, nerve damage, internal bleeding and death. Several strategies for reducing the risks associated with shoulder dystocia are detailed in this article. Consumer tips are also available to encourage women to give their healthcare providers as much of their medical history as possible to help determine the possibility of shoulder dystocia and minimize potential injury.
• Data Snapshot: Maternal Complications: Analysts for the Pennsylvania Patient Safety Authority searched the Authority's reporting system database for maternal complications of pregnancy and childbirth. The analysts limited the search to Serious Events (harm to the patient) among female patients 15 years old and older from June 2004 through August 31, 2009. The search resulted in the identification of 256 reports of maternal complications causing harm to the mother. The ages of the mothers ranged from 16-47 years old. Twenty mothers died. Issues discussed include: uterine ruptures, unplanned transfers to intensive care units, unanticipated blood transfusions, other complications causing significant bleeding, hysterectomies, pulmonary emboli, seizures, primary infections and other complications.

The Authority will send hard copies of the December 2009 Supplementary Pennsylvania Patient Safety Advisory to all clinical directors of abortion facilities and directors of obstetric services in hospitals. These individuals are encouraged to distribute the Supplementary Advisory articles internally to those of the same specialty within their facility.

For an electronic copy of the 2009 December Supplementary Pennsylvania Patient Safety Advisory, go to the Authority's web site at www.patientsafetyauthority.org.