Perinatal Events Analysis Results
General lessons learned

CHPSO recently completed an analysis of perinatal events submitted to the database in the first quarter of 2018. There were a total of 4,798 cases in the final dataset and the analysis of these data revealed the following perinatal specific themes and issues.

  • 3rd/4th degree lacerations
  • Birth trauma
  • Cord prolapse
  • Drug abuse and/or suboptimal prenatal care
  • Fetal demise or neonatal death
  • Fever/ chorioamnionitis/ sepsis
  • Hypertension and preeclampsia
  • Infant care post delivery
  • Maternal morbidity and mortality
  • Meconium
  • Neonatal respiratory distress
  • Neonatal Resuscitation Program (NRP) or transfer to a higher level of care
  • Non-reassuring fetal heart tones or fetal intolerance of labor
  • Placental issues and abnormalities
  • OB hemorrhage
  • Operative vaginal delivery
  • Precipitous birth
  • Shoulder dystocia
  • Vaginal Birth after Cesarean (VBAC) / Trial of Labor after Cesarean (TOLAC)

In addition to a general categorization of events in the dataset, these data were also analyzed for information indicating an opportunity for improvement (OFI). This type of analysis is very valuable as many safety reports contain descriptions of events, with or without harm, which are not preventable. For example, a mother whose care was appropriately managed after presenting to the unit with a pre-viable fetal demise due to head entrapment or cord prolapse would not be an OFI. Likewise, a multiparous woman who arrives in advanced labor and has a precipitous, nurse-assisted birth moments after arrival would not be an OFI. However, a nurse-assisted birth complicated by a shoulder dystocia following repeated attempts to contact the provider would be an OFI.

Aside from the perinatal specific events listed above, there were also a number safety events that occurred in perinatal settings but whose themes are applicable across a variety of settings. These included communication, issues with team dynamics, processes, equipment, person-centered care, retained foreign objects and “other”.

In the communication category there were a total of 494 safety reports, representing 10 percent of the cases. However, nearly all (97 percent) of the reports in this category were identified as an OFI. Examples included repeated attempts to contact providers or team members, refusal by the provider to attend the birth or assess the patient, and the failure of communication devices.

Another category with a high rate of safety reports associated with an OFI were related to team dynamics, processes and/or equipment. There were a total of 1210 reports in this category, representing 25 percent of the total number of cases and nearly all of them (97 percent) represented an OFI. These included reports related to scarcity of resources such as inadequate staffing of nurses and/or providers, inadequate bed capacity, a lack of operating room availability, and insufficient supplies or equipment. Also included in this category were safety reports of failure to follow policies/procedures, staff/team conflict, unprofessional behavior, equipment failure, and Health Information Technology (HIT) issues.

A total of 173 of the safety reports in this dataset were associated with person-centered care and the lessons learned from these reports are also applicable across multiple settings. Among this category of reports, 85 percent represented an OFI. These included a patient and/or family member reporting rude staff/provider behavior and patients feeling unsafe in the care of the team or individual. There were also safety events in this category that reported patient and/or family concerns about care-related decisions, outcomes and the level of communication regarding treatment plans and possible adverse outcomes. This category also included reports related to conflicts arising from the refusal of treatment, either for the mother or the infant.

Fewer reports (n=39, 0.8%) were associated with issues related to retained foreign objects or retained surgical items. Although small in number, there are still valuable lessons to be learned from these reports as 46 percent of these represented an OFI. Examples include providers not waiting for counts to be completed in non-emergent cases and the malfunctioning of count wands. Retained sponges and vaginal packing were also issues found in this category of events.

The final event type in this dataset with applicability across all settings were those classified as “other”, for lack of a more specific descriptor. There were a total 531 cases in this group representing 11 percent of the total, 30 percent of which represented an OFI. These reports included patients leaving against medical advice, mental health crises, patient identification issues and employee injuries such as needle sticks or burns from cautery devices.

These data, while the events were perinatal in nature, provide valuable lessons learned across the spectrum of care. In particular, organizations may find it helpful to examine incidents that fall into categories of events with high rates of OFI such as communication, team dynamics, and person-centered care. The Hospital Quality Institute (HQI) offers many resources to assist organizations in coordinating and supporting patient safety and quality improvement activities. Click here for more information about HQI. Member organizations can learn from analysis of their own events in reports provided by CHPSO as well as from one another by attending safe table discussions on a variety of topics throughout the year. Recent topics have included Language Barriers, Refusal to Permit Medical Treatment, Mass Transfusion Protocol, and Alarm Management. Upcoming safe table topics will include Childbirth After a Prior Cesarean Delivery and Restraints. Click here for more information on safe table meetings and here to see if your organization is a member of CHPSO.