ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Reducing adverse obstetric outcomes through safety sciences

Reducing adverse obstetric outcomes through safety sciences
Literature review current through: Jan 2024.
This topic last updated: Nov 17, 2022.

INTRODUCTION — Patient safety is about minimizing error and preventing harm. Reasons for errors include human fallibility, medical complexity, system deficiencies, and defensive barriers. In 1999, the Institute of Medicine estimated that medical errors account for up to 98,000 deaths each year in the United States [1].

Although there are more than 4 million hospitalizations related to childbirth in the United States each year, there is a paucity of data specifically addressing medical errors in obstetrics. Nevertheless, medical errors do not spare this population and it is likely that strategies to reduce these errors would benefit pregnant women and their children.

Strategies to reduce errors and subsequent adverse outcomes have focused on team and individual training; simulations and drills; development of protocols, guidelines and checklists; use of information technology; and education [1]. These activities and tools apply to inpatient and office settings [2]. Although most studies describe positive reactions among participants and improvements in knowledge, skills, and behavior, data on patient outcomes after clinician-training programs are limited [3]. Simulation training, specifically as it relates to shoulder dystocia management and performance of operative vaginal delivery, has shown the most promise for improving clinical outcomes.

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transmasculine and gender expansive individuals.

TEAMWORK TRAINING — Failures in teamwork and communication account for 70 percent of sentinel events in obstetrics [4]. Recognizing this, the Joint Commission, the American College of Obstetricians and Gynecologists (ACOG), and the Institute of Medicine all acknowledge that teamwork/communication is a critical element of patient safety [1,4,5].

In a labor and delivery setting, the patient and her baby are not cared for solely by her obstetric providers, but also by nurses, anesthesia and pediatric providers, and support staff. Formal teamwork training is increasingly becoming a part of the orientation of new hospital staff members, with the goal of improving teamwork and communication [6,7]. There is some evidence (reviewed below) that formal training in these concepts will improve patient safety, team performance, and maternal-fetal outcomes.

Training methods — A variety of training methods and evaluation tools has been developed and studied, which makes generalization of results difficult. Two of the better-known methods are:

MedTeams training — MedTeams training is an adaptation of a program used for training emergency department personnel and is based on aviation crew resource management principles [8]. Crew resource management has been defined as a management system that makes optimum use of all available resources: equipment, procedures, and people, to promote safety and enhance the efficiency of flight operations [9]. The core concepts of this training program are communication, situation monitoring, mutual support, and leadership [10].

A criticism of the MedTeams approach is its reliance upon the concept of crew resource management at the exclusion of other aspects of team training science.

TeamSTEPPS — A more inclusive teamwork training program that focuses on communication, TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), was created to address the criticism of MedTeams and has been implemented at many military hospitals [11]. Although supporting data on the impact of TeamSTEPPS training are limited, the program appears to be helpful. One study reported a nearly 40 percent reduction in Weighted Adverse Outcome Scores for perinatal morbidity in two hospitals that adopted TeamSTEPPS compared with a control hospital [12].

Obstetric outcomes of teamwork training studies — The following studies represent the available evidence illustrating the modest effects of teamwork training on pregnancy outcome:

Department of Defense randomized trial — The Department of Defense evaluated the effect of teamwork training on adverse maternal and neonatal outcomes in 15 military and civilian hospitals with a combined total of over 53,000 deliveries annually [13]. The intervention group consisted of 1307 labor and delivery personnel randomly assigned to MedTeams training; personnel assigned to the no training group served as controls. Outcomes were recorded before, and five months after, the teamwork training intervention.

The composite maternal and neonatal outcome measure, the Adverse Outcome Index (AOI), was defined as the number of patients with one or more adverse outcomes divided by the total number of deliveries [14]. Adverse maternal outcomes recorded included maternal death, uterine rupture, unplanned admission to an intensive care unit, unplanned return to the operating room, blood transfusion, and third- or fourth-degree vaginal laceration. Adverse neonatal outcomes recorded included intrapartum death of a fetus weighing at least 500 g at 24 or more weeks of gestation, death within seven days of birth of a baby with birth weight of at least 2500 g, neonatal birth trauma, unplanned admission of a term baby to the intensive care nursery, and five-minute Apgar score of less than 7 in a term baby. Additionally, teamwork was measured using 11 process measures that evaluated length of stay and delays in action where multiple care providers were involved.

In both the intervention and control groups, outcomes of approximately 4000 deliveries before training were used for baseline comparisons and 10,000 deliveries after training (or no training) were used for the postintervention evaluation. There were no differences in baseline characteristics or outcomes between the groups. Major findings of the trial were:

There was no statistically significant difference between groups in the individual maternal and neonatal adverse outcomes or in the composite AOI.

Of the 11 process measures evaluated, the only significant difference between groups was that the intervention group had a reduction in the time from decision to proceed with immediate cesarean delivery to the time of incision, which fell from 33 minutes to 21 minutes. The investigators attributed this finding to the formation of contingency teams (obstetric and anesthesia attending physicians, obstetric chief resident, labor nurse and surgical scrub nurse) at the hospitals that received teamwork training and concluded the reduction in decision-to-incision time of 10 minutes may have clinical significance.

The lead civilian hospital in the trial discussed above [13] subsequently implemented a modified version of the original MedTeams teamwork training curriculum for all of their labor and delivery staff and then compared the AOI for the three years prior to program implementation with the AOI four years after implementation; the year that the processes were instituted was excluded [15]. After universal teamwork training, the AOI decreased from 5.9 to 4.6 percent, which represented 300 fewer women experiencing an adverse event. The number of high-severity malpractice claims fell from 13 to 5 cases. Actual incurred indemnity was not addressed.

The investigators suggested that the improvement in outcomes in their study (in contrast to the findings of the original multi-center trial) may have been due to the longer length of follow-up, the creation of other protocols not related to teamwork training, and/or better integration of the teamwork training into practice.

Observational studies — While initial observational data reported improvements in the adverse outcome index (AOI), subsequent studies have reported improvement in patient-specific outcomes.

Specific outcomes – In a 2021 observational study that assessed response to postpartum hemorrhage from uterine atony before and after implementation of a multidisciplinary simulation program, patients treated after the simulation training had lower estimated overall blood loss (1200 versus 1500 mL), received blood products earlier in the first 12 hours following delivery (51 versus 102 minutes), and had reduced variation in time from uterotonic to blood administration [16].

Adverse outcomes index

In a 2012 study that evaluated a combination of MedTeams and simulation training on a labor and delivery unit, a reduction in an AOI was observed at 18 months follow-up [17].

In a 2009 study, a large academic hospital instituted a comprehensive safety strategy including creation of standardized protocols, teamwork training, and training in the interpretation of fetal heart rate monitoring [18]. They used the AOI to evaluate composite outcome.

-After the intervention, the AOI decreased significantly and a provider survey reported significant improvement in the safety climate (ie, the sum of employee perceptions regarding overall safety within the workplace).

-However, there were no significant improvements in the individual outcomes comprising the AOI, other than a decrease in episiotomy rate (which has been falling worldwide anyway). The cesarean delivery rate increased over the study period (as it has worldwide).

-A limitation of this study was that there were no means to determine which of the several safety interventions performed may have led to the modest improvement in outcomes.

Team performance evaluation — Objectively evaluating team performance is a critical step in determining the effect of any teamwork training program. Given modest evidence that teamwork training improves patient safety, it is gaining in popularity [6,19-21]. Further research is needed to determine whether, and what type of, training actually reduces adverse events [22] and the combination of medical didactic training, teamwork theory, and simulation experience that will be most effective [23,24].

The following studies have attempted to create a useful means for objective measurement of teamwork in an obstetric setting, but results have been conflicting. Of note, all of the studies used some sort of rating scale, but none evaluated patient outcomes.

In a 2020 systematic review of nine trials, some, but not all, studies found improvement in patient level composite adverse outcomes after training [25]. All studies that included teamwork evaluation found improvement after their intervention. Included trials were those that sought to improve teamwork during deliveries using various training methods compared with no specific teamwork interventions. Primary outcome was patient outcome, with teamwork outcomes as secondary. Nine studies were included in the analysis, performed in five countries. Over 3800 health care providers and over 107,000 deliveries were observed. Five of the studies evaluated teamwork in simulated deliveries; the other four evaluated teamwork in the clinical setting. Teamwork training included didactic sessions and/or simulations with varying clinical scenarios, including postpartum hemorrhage, shoulder dystocia, and eclampsia.

One study evaluated two tools for rating teamwork in four obstetric emergency scenarios [26]. The first evaluation tool, the Human Factors Rating Scale (HFRS), adapted the Operating Room Management Attitudes' Questionnaire (ORMAQ) to obstetric scenarios. It consisted of a 45 item survey with questions on the themes of leadership-structure, confidence-assertion, information sharing, teamwork, and error. The second evaluation tool consisted of a single five-point rating scale, the Global Rating Scale (GRS), to judge overall team performance. Descriptions of each level of performance along the five-point scale were provided.

These tools were evaluated by having teams complete four obstetric emergency scenarios and then each team member used both evaluation tools (HFRS and GRS) to evaluate the team's performance. Nine external raters used the same evaluation tools to rate the teams. There was good inter-observer reliability among team members and among external raters; however, the correlation between the two groups was poor.

The investigators concluded that the HFRS did not adequately differentiate the difficulty of the individual scenarios. The GRS better identified the more difficult scenarios, but was too simple to separate performance in the various domains of team performance.

Another group created a teamwork evaluation tool using principles of crew resource management [27]. The tool, called the Clinical Teamwork Scale (CTS), evaluates 15 items in the domains of communication, situational awareness, decision making, role responsibility, and patient friendliness. To validate this tool, three evaluators used the CTS to evaluate teams performing a shoulder dystocia drill, comparing their performance with recordings demonstrating good, average, and excellent teamwork. The investigators concluded that the CTS demonstrated good construct validity, usability, and inter-rater reliability.

A British group evaluated team performance in a standardized eclampsia drill before and after eclampsia management training [28]. Although all of the teams received training in eclampsia management, only half of the teams were randomly assigned to also receive formal training in teamwork theory, either at their local hospital or at a regional simulation center. Teamwork performance was evaluated using a validated global rating scale (5-point Likert) to rate areas of knowledge, behavior and overall performance [29].

Teamwork improved in all groups after eclampsia management training, but there was no additional benefit noted in those groups that also received teamwork training. The investigators suggested that the apparent lack of benefit of formal teamwork training may have been due to inadequate training in teamwork issues. It is also possible that simply receiving eclampsia education and rehearsing the eclampsia drill was sufficient to improve teamwork because of the relatively straightforward nature of eclampsia management.

This conclusion was supported by a separate analysis of the participants' change in medical knowledge before and after training [30]. Medical knowledge was assessed using a 185 question, multiple-choice questionnaire, administered one to three weeks before the training and again one to three weeks afterwards. All of the teams had a 20-point increase in test scores after eclampsia education and drill training, but there was no difference between the teams with and without teamwork training.

SIMULATION AND DRILLS — Simulation of obstetric procedures has become a common method of training individuals and teams to improve technical skills for treating emergency situations that occur infrequently. By simulating these situations, teams can learn and practice the required interventions in a safe environment, and thus potentially improve patient outcome when these situations actually occur on the labor unit. Simulation can also identify individual and team weaknesses [31]. Observations of many providers performing the same simulation can reveal the most common mistakes, allowing for development of appropriate and efficient curriculum for future training [32,33]. Lastly, simulation can augment the perceived reduction in clinical experience due to mandated reductions in resident work hours [34,35].

The American College of Obstetricians and Gynecologists (ACOG) proposed a series of obstetric scenarios amenable to simulation training and the Society for Maternal-Fetal Medicine's simulation subcommittee developed a classification system for the characterization of evidence for simulation [36].

Summary of outcomes — In general, the available data consistently show simulation training and drills improve performance by various measures, but there is less evidence for improvement in maternal or neonatal outcomes [37,38]. A 2022 meta-analysis of four trials and 17 cohort studies that compared patient outcomes after obstetric team training versus no training reported some evidence of reduced brachial plexus injury following training but no impact on risk of Apgar score below 7 at five minutes [39]. The effect was unclear for reducing hypoxic-ischemic encephalopathy, time to emergency cesarean delivery, or severe postpartum hemorrhage. Due to the heterogeneity of included training methods, conclusions about the best type and frequency of training could not be made.

The results of simulation drills in specific common obstetric emergencies are reviewed below.

Eclampsia — Eclampsia simulation has offered insights into individual, team, and system errors that can be prevented [40]. Realism can be added to the simulation of eclampsia and hemorrhage with modifications of commonly used models [41].

Improvement in task completion – A study performed in the United Kingdom compared team performance before and after eclampsia drill training [28]. Teams were randomly assigned to training at their local hospital or in a regional simulation center. After training, the teams completed more of the basic tasks required in the management of eclamptic patients, and these tasks were completed more quickly than prior to training. There were no differences between the teams trained locally or at a simulation center.

Opportunities for improvement – Another study of simulation to evaluate team management of eclampsia identified areas for improvement in the use of antihypertensive medications to treat severe hypertension and inconsistent use of checklists even when immediately available [42].

Shoulder dystocia — Shoulder dystocia is an obstetric emergency with the potential for serious neonatal and/or maternal adverse outcome. It is usually unpredictable and unpreventable. Improper management of this emergency may worsen neonatal outcome, highlighting the need for adequate training of providers. The infrequent nature and special skills needed to manage shoulder dystocia combine to make it an obstetric emergency ideally suited for simulation. Also, there are evidence-based recommendations for the proper selection, sequence, and technique of maneuvers used to resolve shoulder dystocia; these recommendations can be used to develop training programs [43].

Benefits of training

Improved simulation performance – Several studies have demonstrated improvement in management and documentation of a simulated shoulder dystocia event after training of residents and attending physicians [44-46]. Both low- and high-fidelity simulation of shoulder dystocia improved performance in the simulated event [47]. However, there are no studies evaluating post-training team performance during actual patient events.

Reduced brachial plexus injury – Neonatal outcomes after team simulation training have been evaluated. Several studies have reported reductions in the frequency of brachial plexus injury associated with shoulder dystocia of at least two-thirds after training [48-51].

-In a single center Finnish study that compared the incidence of shoulder dystocia and brachial plexus injury before and after the institution of regular simulation training, training was associated with a higher rate (0.1 versus 0.3 percent) of shoulder dystocia but a lower rate of permanent brachial plexus injury (0.05 versus 0.02 percent) [52]. In addition, delivery of the posterior arm was successful in more cases after training (11.3 versus 23.4 percent). Training consisted of regular three-hour sessions for a small team of midwives and physicians and monthly "walk-in" sessions for further practice. The training reviewed all techniques for resolving shoulder dystocia but placed emphasis on delivery of the posterior arm. There were over 113,000 deliveries in their cohort: 59,709 before and 54,076 after the training program was initiated.

-A retrospective study compared shoulder dystocia management and neonatal outcomes in the four years before versus after institution of a training program [48]. Training consisted of didactic and practical training on risk factors, diagnosis, and proper management of shoulder dystocia. The rate of shoulder dystocia was similar during both periods (approximately 2 percent), but neonatal brachial plexus injury fell significantly from 9.3 percent to 2.3 percent. A significant improvement was noted in use of appropriate management techniques (McRoberts' position, suprapubic pressure, internal rotation maneuvers, delivery of the posterior arm) and a significant decrease was also noted in inappropriate techniques (no recognized maneuvers performed, excessive traction, fundal pressure). Before training, the use of at least one correct maneuver was documented in only 49 percent of deliveries, versus 92 percent of deliveries after training.

-A subsequent 12-year follow-up study reported a sustained reduction in brachial plexus injury at birth: 24/324 (7.4 percent, p <0.01) pretraining, 6/262 (2.3 percent) early after training, and 7/562 (1.3 percent) late after training. The authors concluded that there are significant benefits to long-term, embedded training programs with improvements in management and outcomes. Importantly, a decade after the introduction of simulation training there were no cases of brachial plexus injury lasting over 12 months in 562 cases of shoulder dystocia [51].

Lack of benefit – A study comparing brachial plexus injury frequency between time periods before and after team training and use of simulators did not find a significant reduction in brachial plexus injuries after [53]. The authors postulated that this may be because many of these injuries were not due to excessive traction by the clinician, and therefore not modifiable by clinician training. Other confounders may have been the observational nature of the study and small numbers of events in both groups.

Operative vaginal delivery — Operative vaginal delivery, specifically forceps delivery, is another area in which simulation training has been associated with improved clinical outcomes. Many residents do not feel competent in the performance of a forceps delivery [54]. It is likely that this accounts for at least a portion of the increasing number of cesarean deliveries [55,56].

Adequate training in forceps delivery is likely going to require simulation for a number of reasons [57]. The number of faculty capable of teaching the use of forceps is declining; teaching the proper use of obstetric forceps in the clinical setting is difficult because they are primarily used in urgent or emergency situations, and the key maneuvers of blade placement by the learner are done in the vagina, thus the teacher is blind to whether placement is correct until it is complete.

To overcome these obstacles, one group of investigators created a forceps simulation system using blades implanted with position sensors, allowing real-time and postsimulation evaluation of blade trajectory during placement [58,59]. Based on objective assessment of blade trajectory and repeatability of insertion technique, the investigators found that senior obstetricians performed forceps placements in an "excellent," "very good," or "good" manner 92 percent of the time, compared with only 38 percent of the time for junior obstetricians. They also observed that residents' skills progressed with more training, showing less hesitation and better following of a trajectory modeled by an expert operator [60].

A 2019 systematic review evaluated studies of operative vaginal delivery simulation in which provider or patient outcomes were reported [61]. Eight studies were included, and participants in the training programs were resident and/or attending physicians. Most of the studies were of forceps training. Only two studies included patient-level outcomes and are described below.

Reduced neonatal intensive care unit admissions – One study evaluated the effect of operative vaginal delivery training on maternal and neonatal outcomes [62]. Training sessions with a senior staff member included lecture, video, and a "doll and pelvis" model. Materials were also provided for later individual study. This training emphasized techniques to minimize maternal and neonatal injury and to reduce the number of failed instrumental deliveries. Operative vaginal delivery rates were 11 percent before, and 14 percent after, the training period, similar to the overall rate of operative vaginal delivery in the United States. A comparison between outcomes for all operative vaginal deliveries in the four months after initiation of the training program with that of a historical control group reported no statistically significant difference in the incidence of failed forceps or vacuum delivery or maternal anal sphincter injury. There was, however, a significant reduction in neonatal admissions to a special care nursery and in neonatal scalp and facial injuries. The investigators theorized that the improvement in neonatal outcome may have been largely due to better understanding of the correct technique of vacuum delivery, given that this was the more commonly used method.

Reduced severe perineal lacerations – In a second study, implementation of forceps simulation curriculum for residents in training demonstrated a 22 percent decrease in severe maternal perineal lacerations. After adjusting for known maternal and delivery risk factors for perineal laceration, the magnitude of the reductions increased to 26 percent in the full dataset model (odds ratio 0.74, p = 0.002) [63].

Postpartum hemorrhage — Postpartum hemorrhage (PPH) is a relatively common, potentially life-threatening obstetric emergency. Studies of simulation-based teaching of management of PPH have demonstrated that this approach identifies important deficiencies in clinician knowledge and performance [33,64]. Common management errors were delay in transporting the bleeding patient to the operating room, unfamiliarity with prostaglandin administration to reverse uterine atony, poor cardiopulmonary resuscitation techniques, and delayed administration of blood products to reverse consumption coagulopathy [33]. One study reported improvement in knowledge of clinical management of PPH, clinician confidence, and communication skills when assessed three months after training [65], and another reported improved skills of birth attendants to correctly perform bimanual uterine compression [66]. There are data from developing countries demonstrating benefit of PPH training. For example, a hospital in Tanzania reported a reduction in blood transfusion rate after multidisciplinary training for the management of hemorrhage [67]. However, data on the clinical effect of postpartum training in developed countries are lacking.

Perimortem cesarean delivery — Perimortem cesarean delivery is a key component of the management of cardiac arrest in pregnancy, and can be life-saving for the mother and/or fetus. Delivery of the infant within five minutes of maternal cardiac arrest is critical. (See "Sudden cardiac arrest and death in pregnancy", section on 'Delivery as part of the resuscitation process'.)

The Managing Obstetric Emergencies and Trauma (MOET) course, which includes perimortem cesarean delivery, provides clinicians with a systematic approach to dealing with obstetric emergencies. A retrospective study found that performance of perimortem cesarean delivery significantly increased after the course (from four procedures or 0.36/year to eight procedures or 1.6/year), although none of the cesareans was performed within the recommended five minutes after starting resuscitation [68]. Nevertheless, 8 of the 12 women regained cardiac output after delivery, with two maternal and five neonatal survivors.

In another study, maternal-fetal medicine staff (attendings and fellows) demonstrated significant improvement in knowledge, confidence, and management after participating in a simulated-based curriculum for managing maternal cardiac arrest [69]. The educational intervention included the American Heart Association Basic Life Support training followed by a didactic session focusing on the management of cardiac arrest during pregnancy. Participants then participated in a simulation session with immediate feedback, completed a multiple choice test, and took a confidence survey. Postintervention evaluation three weeks later showed significant improvement in simulation performance, knowledge and confidence. Significant improvements occurred in timely initiation of cardiopulmonary resuscitation (median 32 versus 120 seconds) and timely initiation of cesarean delivery (median time 159 versus 240 seconds).

Other procedures — The use of simulators has been demonstrated to improve performance of amniocentesis [70] and vaginal breech delivery [71].

A retrospective study investigated the benefit of a structured training course on neonatal outcomes [72]. The course lasted a full day, with didactic training in electronic fetal monitoring in the morning, followed by an afternoon session of emergency drills to review the management of shoulder dystocia, PPH, eclampsia, twins, breech, and adult and neonatal resuscitation.

Review of neonatal outcomes before and after implementation of the training sessions showed a significant reduction in five-minute Apgar scores <7 and hypoxic-ischemic encephalopathy. Infants born <37 weeks of gestation, multiple pregnancies, infants born breech (either vaginally or by cesarean) and those born by elective cesarean were excluded, and maternal outcomes were not evaluated.

Retention of skills — One concern with using simulation training is the retention of skills. If training can help reduce adverse outcomes, it is important to know how frequently it must be performed.

This issue was addressed in a study of skill retention after simulation training for management of shoulder dystocia [73]. The training session included a 40-minute practical workshop on shoulder dystocia management. Participants, including junior and senior physicians and midwives, performed a simulated delivery with a shoulder dystocia. The simulation ended when the participant delivered the posterior arm, elected to stop, or five minutes had elapsed. They were evaluated on whether delivery was successful, the head-to-body delivery interval, performance of appropriate actions, force applied, and communication.

Each participant did the simulation once before the training session and at three time points after training. The fetus with shoulder dystocia was successfully delivered in 49 percent of simulations before training, and in 82, 84, and 85 percent of simulations at 3 weeks, 6 months, and 12 months after training, respectively. Additional training of the 18 percent of participants who were unable to deliver the fetus 3 weeks after training resulted in a 79 percent rate of successful delivery in this group at 12 months.

The investigators concluded that annual training is adequate for providers demonstrating competency after initial training. However, those that were unsuccessful three weeks after training should have remediation and be followed more closely to ensure retention of skills. This study also highlights the fact that providers do not all learn in the same way or at the same rate and that to achieve maximal benefit, some individualization of simulation training is required.

Implementation of simulation programs — Although the evidence for supporting the effectiveness of simulation and patient safety practices has increased, the ability to implement programs to positively impact clinical outcomes across multiple clinical sites and institutions is lacking. A group of five academic medical centers and affiliated hospitals identified key components for successfully initiating and implementing a shoulder dystocia simulation program, which included: involvement of clinician and nursing leadership from each academic medical center, administrative and logistic support from a liability insurer, development of consensus on curriculum components of simulation curriculum, conduct of a gap and barrier analysis, financial support from insurer to close necessary gaps and mitigate barriers, and creation of dashboards and tracking program performance [74].

CHECKLISTS — Checklists are available from several sources, including:

World Health Organization safe childbirth checklist

The Society for Maternal-Fetal Medicine

Oxytocin administration — Oxytocin is a commonly used medication to stimulate labor. While many dose regimens have been evaluated, there is insufficient evidence to recommend a dosing protocol that is appropriate for all patients. The best dose regimen likely varies among patients or types of patients. It is possible, however, that more uniform practice could improve safety. Some experts recommend oxytocin protocols, which emphasize strict maternal and fetal criteria when administering the medication, the use of low initial doses with infrequent dose increases, and strong collaboration between physicians and nurses. Adherence to protocols and checklists may reduce medicolegal risk, while establishing protocols/checklists and then violating them may increase that risk [75-78].

Use of a checklist in a single hospital system – A large hospital corporation published data on the effects of implementing a checklist-based system for use of oxytocin [79]. They purposely created a "conservative" protocol with the intention that a standing order could be safely implemented by nurses of all skill levels. The pre-oxytocin checklist required adequate documentation that the patient was an appropriate candidate for labor (appropriate estimated fetal weight, fetal presentation, clinical pelvimetry, fetal assessment, etc). An "in-use" oxytocin checklist included fetal assessment by heart rate pattern and uterine assessment by pattern and strength of contractions (either by palpation or with an intrauterine pressure catheter); this checklist was to be completed every 30 minutes while the patient received the medication. If all of the items on the checklist could not be completed, then the oxytocin infusion was reduced or stopped. The infusion could be restarted if both the pre-oxytocin and in-use checklist were completed.

To evaluate the effect of the checklist, the investigators compared the outcomes of 100 patients in one hospital who received oxytocin just before implementation of the checklist-based protocol with the outcome of 100 patients who received oxytocin just after implementation of the checklist. The groups were similar at baseline and had a similar total duration of oxytocin infusion. There were no differences between groups in cesarean delivery rates or specific adverse neonatal outcomes (intensive care nursery admission, respiratory distress, sepsis suspected or confirmed). There was a clinically negligible, but statistically significant, reduction in maximum oxytocin dose from 13.8 mU/min to 11.4 mU/min and a reduction in the total number of neonates with any adverse outcome, which fell from 31 to 18 neonates.

Based on the perceived success of the oxytocin checklist, the same hospital corporation instituted similar checklists for the use of misoprostol and magnesium sulfate, the performance of operative vaginal delivery, and the management of shoulder dystocia and abnormal fetal heart rate tracings [80]. They subsequently observed a decrease in litigation, as well as a one-year reduction in the cesarean delivery rate. No further data were provided about maternal or neonatal outcome. Ascribing all of the positive outcomes to implementation of checklists may not be warranted, as the hospital corporation employed several other initiatives during this period, such as increased physician presence in the hospitals. Their approach to patient safety now encompasses 11 principles [81].

Mixed results of checklist use at other institutions – Other studies of oxytocin checklists or protocols have mixed results. After initiating a checklist as part of a quality improvement project, one group found a decrease in uterine tachysystole, cesarean deliveries for nonreassuring fetal heart rate, shorter first stage of labor, and a lower maximum dose of oxytocin [82]. Another group, however, found potential adverse changes after initiating a checklist-based, low-dose oxytocin protocol, including longer median time from admission to delivery, increased cesareans for labor dystocia, and higher rates of chorioamnionitis [83]. Finally, the use of an institutional checklist for oxytocin administration did not improve actual use of oxytocin based on expert review of cases of emergency cesarean deliveries for nonreassuring fetal heart rate tracings [84].

PRACTICE GUIDELINES AND PROTOCOLS — Consistent use of well-developed, evidence-based practice guidelines results in universal application of best practices and can improve patient outcomes, as illustrated by the following examples. (See "Overview of clinical practice guidelines".)

Late preterm elective delivery — The Ohio Perinatal Quality Collaborative, recognizing the increased rates of neonatal morbidity for infants born at <39 completed weeks of gestation, sought to reduce overall morbidity by reducing elective deliveries between 36+0 and 38+6 weeks [85]. The group created a set of recommended practices, including promotion of ultrasound examination before 20 weeks of gestation to confirm dating, utilization of the American College of Obstetricians and Gynecologists (ACOG) criteria for scheduled birth, improving communication between obstetric and pediatric providers and promoting a culture of safety. These interventions resulted in a decrease in the rate of elective scheduled births from 25 percent before implementation to <5 percent after.

Third- and fourth-degree lacerations — In order to reduce the frequency of third- and fourth-degree lacerations associated with operative vaginal delivery, one institution instituted a training program and provided practice guidelines for this procedure [86]. Recommendations included using vacuum extraction instead of forceps when possible, converting occiput posterior to occiput anterior prior to delivery, and performing a mediolateral episiotomy if an episiotomy was necessary. The guidelines were promulgated via departmental conferences, distribution of reading materials, and instructional posters.

The investigators reviewed outcomes for the nine months before the intervention began and for the first nine months afterwards. After the training and guidelines were initiated, there was a significant increase in the use of vacuum rather than forceps and a significant reduction in the frequency of third and fourth decree lacerations related to operative vaginal deliveries, from 41 percent to 26 percent. Among these patients, the incidence of fourth-degree lacerations decreased from 30 to 19 percent. There were no differences in neonatal outcomes (admission to neonatal intensive care unit, transfusion, Apgar scores, intraventricular hemorrhage, nerve injury, or laceration).

Peripartum hemorrhage — In one study, a hospital implemented a comprehensive program to improve patient safety following the deaths of two patients from hemorrhage [87]. Training sessions discussing the new guidelines, as well as the recognition and management of severe obstetric hemorrhage, were regularly performed. The program consisted of several components:

Obstetric rapid response teams to respond to obstetric emergencies.

Performance of quarterly drills of various emergencies.

Development of clinical guidelines and pathways.

Relieving the in-house obstetrician of caring for gynecologic emergencies and asking this physician to monitor all patients on labor and delivery, regardless of who their primary physician was.

A policy whereby all members of the labor and delivery team were empowered to consult with a senior department member if there was a disagreement about the care of a patient. This senior physician would immediately discuss the issue with the attending physician.

The hospital's trauma team, as experts in hemorrhagic shock, was made available to consult on all cases of severe obstetric hemorrhage.

To evaluate the effect of this intervention, the investigators compared patient outcomes from the year prior to the intervention with outcomes four years after its implementation. Patient characteristics were similar between the two periods, as was the occurrence of placenta accreta and the severity of hemorrhage. Maternal deaths due to hemorrhage decreased from two to none. The small number of serious events precludes drawing conclusions regarding the effectiveness of this program. However, there was a significant improvement in nonspecific markers of effective resuscitation, such as maternal pH and temperature.

In a second study, another hospital evaluated all of their cases of massive (defined at >1000 mL) postpartum hemorrhage (PPH) over a six-month period in an attempt to improve management of this complication [88]. Each case was examined to identify deviation from hospital guidelines. The guidelines were then revised to reduce practice deviation, the staff was trained in management of PPH, and practice drills were implemented.

Deviations from guidelines fell from 37 percent in the initial six-month period to none in the second six-month period. The incidence of massive PPH fell from 1.7 percent to 0.45 percent and there were fewer blood transfusions and admissions to higher level care units.

The Council on Patient Safety in Women's Health Care is comprised of key stakeholders in women's health care with the mission to improved patient safety through multidisciplinary collaboration. The council has created several "bundles" that provide curated lists of resources for several obstetric topics including obstetric hemorrhage, maternal venous thromboembolism, and severe hypertension in pregnancy. Each bundle references resources for four key areas of emergency management: readiness, recognition and prevention, response, and reporting/systems learning.

INFORMATION TECHNOLOGY — A systematic review including 257 studies evaluated evidence on the effect of health information technology on quality, efficiency, and cost of care [89]. Of note, there were few studies focused on obstetrics and only four academic institutions accounted for 25 percent of these publications.

Use of information technology was associated with three major benefits with respect to quality of care: increased adherence to guideline based care; enhanced patient surveillance and monitoring; and decreased medication errors.

Several obstetric early warning systems have been described that aim to detect signs of clinical deterioration of vital signs with the goal of early intervention. Information technology can be utilized to alert members of the care team when warning thresholds are crossed. A 2019 systematic review of early warning systems evaluated 16 studies of their use and concluded that they can potentially improve care by increasing vital sign assessments and may decrease some morbidities [90].

UNIT-BASED PROGRAMS — The Comprehensive Unit-Based Safety Program (CUSP) is a safety culture program designed to educate and improve awareness about patient safety and quality of care, empower staff to take charge and improve safety in their unit, create partnerships between units and hospital managers to improve organizational culture and provide resources for unit improvement efforts, and provide tools to investigate and learn from defects [91]. The program uses a structured process that allows it to be integrated into the hospital's strategic plan, while taking advantage of local unit's experience. Key elements of the program include:

Staff education on safety science.

Identification of potential hazards.

Partnering with a hospital executive.

Learning from previous problems. This requires answering four questions: What happened? Why did it happen? What was done to reduce risk? How do we know that the risk was actually reduced?

Implementing tools to improve teamwork, communication, and the culture of safety.

Ongoing measurement, feedback, and improvement.

A pre- and postimplementation evaluation of CUSP in two surgical intensive care units at Johns Hopkins Hospital found it was associated with an improvement in safety culture and a reduction in length of stay, medication errors, and possibly nursing turnover [91-93].

RESIDENT EDUCATION AND WORK HOURS — In 2003, the Accreditation Council for Graduate Medical Education (ACGME) established the 80-hour work week for all residency programs. Subsequently, the Institute of Medicine released a report recommending adjustments to the ACGME guidelines, including reductions in maximum shift length without time for sleep and number of consecutive night shifts [94]. These guidelines were based on research into sleep and human performance and were instituted without evidence that they reduce adverse events by resident physicians. Although surveys after initiation of reduced work hours reported some improvements in the personal lives and morale of residents [95-97], there is limited evidence that mandated reduction in obstetric resident work hours has reduced adverse obstetric outcomes [98]. Some have suggested that the lack of proven benefit of reduced work hours for improving patient safety is a problem with supervision, rather than with resident performance [99-101].

One study compared several obstetric outcomes before and after the work rule changes [98]. There was a reduction in neonatal resuscitations (potentially related to changes in management of meconium-stained fluid) and maternal hemorrhage. There were no statistically significant changes in other outcomes, including primary cesarean delivery rate, low neonatal cord pH, or severe vaginal lacerations. A Canadian study compared obstetric outcomes after implementation of a night-float system to replace 24-hour shifts [102]. The authors reported an increase in a composite surgical/obstetric adverse outcome measure as well as increases in transfusions and/or hemorrhage. These findings are contrary to the expectation that reduced shift lengths would improve outcomes; the authors posit this could be related to increased patient handoffs. At a high-volume academic center after work hour changes, there was an increase in the mean time to complete an uncomplicated cesarean delivery from 43.3 to 59.5 minutes [103]. It is uncertain if this increase in operative time was caused by the reduction in resident duty hours or other changes in training, such as is seen in gynecologic surgery (eg, laparoscopic approaches replacing many laparotomies).

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Patient safety in the operating room".)

SUMMARY AND RECOMMENDATIONS

Clinical issue – There is a paucity of data specifically addressing medical errors in obstetrics. Nevertheless, medical errors do not spare this population and it is likely that strategies to reduce these errors would benefit pregnant women and their children. (See 'Introduction' above.)

Contributors to sentinel events – Teamwork and communication failures contribute to 70 percent of sentinel events in obstetrics. (See 'Teamwork training' above.)

Role of simulation training – Available data, mainly observational, suggest simulation training improves clinician performance in multiple obstetric simulation scenarios. (See 'Simulation and drills' above.)

Brachial plexus injury – Simulation training in the management of shoulder dystocia appears to reduce the incidence of brachial plexus injury in the newborn. (See 'Shoulder dystocia' above.)

Maternal perineal laceration – Simulation training in forceps delivery is associated with a reduction in severe maternal perineal trauma. (See 'Operative vaginal delivery' above.)

Tools to improve patient safety – Multifaceted approaches to enhance the overall safety climate include use of clinical protocols, guidelines, and checklists. (See 'Checklists' above and 'Practice guidelines and protocols' above.)

  1. Kohn, LT, Corrigan, JM, Donaldson, MS, Eds; Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
  2. Erickson TB, Kirkpatrick DH, DeFrancesco MS, Lawrence HC 3rd. Executive summary of the American College of Obstetricians and Gynecologists Presidential Task Force on Patient Safety in the Office Setting: reinvigorating safety in office-based gynecologic surgery. Obstet Gynecol 2010; 115:147.
  3. van Lonkhuijzen L, Dijkman A, van Roosmalen J, et al. A systematic review of the effectiveness of training in emergency obstetric care in low-resource environments. BJOG 2010; 117:777.
  4. Joint Commission on Accreditation of Healthcare Organizations. JCAHO sentinel event alert #30. 2004.
  5. Committee opinion no. 590: preparing for clinical emergencies in obstetrics and gynecology. Obstet Gynecol 2014; 123:722.
  6. Birnbach DJ, Salas E. Can medical simulation and team training reduce errors in labor and delivery? Anesthesiol Clin 2008; 26:159.
  7. Hunt EA, Shilkofski NA, Stavroudis TA, Nelson KL. Simulation: translation to improved team performance. Anesthesiol Clin 2007; 25:301.
  8. Morey JC, Simon R, Jay GD, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Serv Res 2002; 37:1553.
  9. www.raes-hfg.com/reports/crm-now.htm (Accessed on July 27, 2009).
  10. Mann S, Pratt SD. Team approach to care in labor and delivery. Clin Obstet Gynecol 2008; 51:666.
  11. Alonso A, Baker DP, Holtzman A, et al. Reducing medical error in the Military Health System: How can team training help? Human Resource Management Review 2006; 16:396.
  12. Riley W, Davis S, Miller K, et al. Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital. Jt Comm J Qual Patient Saf 2011; 37:357.
  13. Nielsen PE, Goldman MB, Mann S, et al. Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial. Obstet Gynecol 2007; 109:48.
  14. Mann S, Pratt S, Gluck P, et al. Assessing quality obstetrical care: development of standardized measures. Jt Comm J Qual Patient Saf 2006; 32:497.
  15. Pratt SD, Mann S, Salisbury M, et al. John M. Eisenberg Patient Safety and Quality Awards. Impact of CRM-based training on obstetric outcomes and clinicians' patient safety attitudes. Jt Comm J Qual Patient Saf 2007; 33:720.
  16. Dillon SJ, Kleinmann W, Fomina Y, et al. Does simulation improve clinical performance in management of postpartum hemorrhage? Am J Obstet Gynecol 2021; 225:435.e1.
  17. Phipps MG, Lindquist DG, McConaughey E, et al. Outcomes from a labor and delivery team training program with simulation component. Am J Obstet Gynecol 2012; 206:3.
  18. Pettker CM, Thung SF, Norwitz ER, et al. Impact of a comprehensive patient safety strategy on obstetric adverse events. Am J Obstet Gynecol 2009; 200:492.e1.
  19. Haller G, Garnerin P, Morales MA, et al. Effect of crew resource management training in a multidisciplinary obstetrical setting. Int J Qual Health Care 2008; 20:254.
  20. Nielsen P, Mann S. Team function in obstetrics to reduce errors and improve outcomes. Obstet Gynecol Clin North Am 2008; 35:81.
  21. Scholefield H. Safety in obstetric critical care. Best Pract Res Clin Obstet Gynaecol 2008; 22:965.
  22. Read JS, Cannon MJ, Stanberry LR, Schuval S. Prevention of mother-to-child transmission of viral infections. Curr Probl Pediatr Adolesc Health Care 2008; 38:274.
  23. Guise JM, Segel S. Teamwork in obstetric critical care. Best Pract Res Clin Obstet Gynaecol 2008; 22:937.
  24. McConaughey E. Crew resource management in healthcare: the evolution of teamwork training and MedTeams. J Perinat Neonatal Nurs 2008; 22:96.
  25. Wu M, Tang J, Etherington C, et al. Interventions for improving teamwork in intrapartem care: a systematic review of randomised controlled trials. BMJ Qual Saf 2020; 29:77.
  26. Morgan PJ, Pittini R, Regehr G, et al. Evaluating teamwork in a simulated obstetric environment. Anesthesiology 2007; 106:907.
  27. Guise JM, Deering SH, Kanki BG, et al. Validation of a tool to measure and promote clinical teamwork. Simul Healthc 2008; 3:217.
  28. Ellis D, Crofts JF, Hunt LP, et al. Hospital, simulation center, and teamwork training for eclampsia management: a randomized controlled trial. Obstet Gynecol 2008; 111:723.
  29. Weller JM, Bloch M, Young S, et al. Evaluation of high fidelity patient simulator in assessment of performance of anaesthetists. Br J Anaesth 2003; 90:43.
  30. Crofts JF, Ellis D, Draycott TJ, et al. Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomised controlled trial of local hospital, simulation centre and teamwork training. BJOG 2007; 114:1534.
  31. Daniels K, Lipman S, Harney K, et al. Use of simulation based team training for obstetric crises in resident education. Simul Healthc 2008; 3:154.
  32. Crofts JF, Fox R, Ellis D, et al. Observations from 450 shoulder dystocia simulations: lessons for skills training. Obstet Gynecol 2008; 112:906.
  33. Maslovitz S, Barkai G, Lessing JB, et al. Recurrent obstetric management mistakes identified by simulation. Obstet Gynecol 2007; 109:1295.
  34. Johannsson H, Ayida G, Sadler C. Faking it? Simulation in the training of obstetricians and gynaecologists. Curr Opin Obstet Gynecol 2005; 17:557.
  35. Macedonia CR, Gherman RB, Satin AJ. Simulation laboratories for training in obstetrics and gynecology. Obstet Gynecol 2003; 102:388.
  36. Argani CH, Eichelberger M, Deering S, Satin AJ. The case for simulation as part of a comprehensive patient safety program. Am J Obstet Gynecol 2012; 206:451.
  37. Merién AE, van de Ven J, Mol BW, et al. Multidisciplinary team training in a simulation setting for acute obstetric emergencies: a systematic review. Obstet Gynecol 2010; 115:1021.
  38. Hernández E, Camacho M, Leal-Costa C, et al. Does Multidisciplinary Team Simulation-Based Training Improve Obstetric Emergencies Skills? Healthcare (Basel) 2021; 9.
  39. Brogaard L, Glerup Lauridsen K, Løfgren B, et al. The effects of obstetric emergency team training on patient outcome: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2022; 101:25.
  40. Thompson S, Neal S, Clark V. Clinical risk management in obstetrics: eclampsia drills. BMJ 2004; 328:269.
  41. Daniels K, Parness AJ. Development and use of mechanical devices for simulation of seizure and hemorrhage in obstetrical team training. Simul Healthc 2008; 3:42.
  42. Hilton G, Daniels K, Carvalho B. Simulation Study Assessing Healthcare Provider's Knowledge of Pre-Eclampsia and Eclampsia in a Tertiary Referral Center. Simul Healthc 2016; 11:25.
  43. Gurewitsch ED. Optimizing shoulder dystocia management to prevent birth injury. Clin Obstet Gynecol 2007; 50:592.
  44. Deering S, Poggi S, Macedonia C, et al. Improving resident competency in the management of shoulder dystocia with simulation training. Obstet Gynecol 2004; 103:1224.
  45. Goffman D, Heo H, Pardanani S, et al. Improving shoulder dystocia management among resident and attending physicians using simulations. Am J Obstet Gynecol 2008; 199:294.e1.
  46. Goffman D, Heo H, Chazotte C, et al. Using simulation training to improve shoulder dystocia documentation. Obstet Gynecol 2008; 112:1284.
  47. Crofts JF, Bartlett C, Ellis D, et al. Training for shoulder dystocia: a trial of simulation using low-fidelity and high-fidelity mannequins. Obstet Gynecol 2006; 108:1477.
  48. Draycott TJ, Crofts JF, Ash JP, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol 2008; 112:14.
  49. Inglis SR, Feier N, Chetiyaar JB, et al. Effects of shoulder dystocia training on the incidence of brachial plexus injury. Am J Obstet Gynecol 2011; 204:322.e1.
  50. Grobman WA, Miller D, Burke C, et al. Outcomes associated with introduction of a shoulder dystocia protocol. Am J Obstet Gynecol 2011; 205:513.
  51. Crofts JF, Lenguerrand E, Bentham GL, et al. Prevention of brachial plexus injury-12 years of shoulder dystocia training: an interrupted time-series study. BJOG 2016; 123:111.
  52. Kaijomaa M, Gissler M, Äyräs O, et al. Impact of simulation training on the management of shoulder dystocia and incidence of permanent brachial plexus birth injury: An observational study. BJOG 2023; 130:70.
  53. Walsh JM, Kandamany N, Ni Shuibhne N, et al. Neonatal brachial plexus injury: comparison of incidence and antecedents between 2 decades. Am J Obstet Gynecol 2011; 204:324.e1.
  54. Powell J, Gilo N, Foote M, et al. Vacuum and forceps training in residency: experience and self-reported competency. J Perinatol 2007; 27:343.
  55. Maulik D. Adequate training for operative vaginal delivery. J Matern Fetal Neonatal Med 2004; 16:145.
  56. Bailey PE. The disappearing art of instrumental delivery: time to reverse the trend. Int J Gynaecol Obstet 2005; 91:89.
  57. Shaffer BL, Caughey AB. Forceps delivery: potential benefits and a call for continued training. J Perinatol 2007; 27:327.
  58. Dupuis O, Moreau R, Silveira R, et al. A new obstetric forceps for the training of junior doctors: a comparison of the spatial dispersion of forceps blade trajectories between junior and senior obstetricians. Am J Obstet Gynecol 2006; 194:1524.
  59. Dupuis O, Moreau R, Pham MT, Redarce T. Assessment of forceps blade orientations during their placement using an instrumented childbirth simulator. BJOG 2009; 116:327.
  60. Moreau R, Jardin A, Pham MT, et al. A new kind of training for obstetric residents: simulator training. Conf Proc IEEE Eng Med Biol Soc 2006; 1:4416.
  61. Bligard KH, Lipsey KL, Young OM. Simulation Training for Operative Vaginal Delivery Among Obstetrics and Gynecology Residents: A Systematic Review. Obstet Gynecol 2019; 134 Suppl 1:16S.
  62. Cheong YC, Abdullahi H, Lashen H, Fairlie FM. Can formal education and training improve the outcome of instrumental delivery? Eur J Obstet Gynecol Reprod Biol 2004; 113:139.
  63. Gossett DR, Gilchrist-Scott D, Wayne DB, Gerber SE. Simulation Training for Forceps-Assisted Vaginal Delivery and Rates of Maternal Perineal Trauma. Obstet Gynecol 2016; 128:429.
  64. Deering SH, Chinn M, Hodor J, et al. Use of a postpartum hemorrhage simulator for instruction and evaluation of residents. J Grad Med Educ 2009; 1:260.
  65. Birch L, Jones N, Doyle PM, et al. Obstetric skills drills: evaluation of teaching methods. Nurse Educ Today 2007; 27:915.
  66. Andreatta P, Gans-Larty F, Debpuur D, et al. Evaluation of simulation-based training on the ability of birth attendants to correctly perform bimanual compression as obstetric first aid. Int J Nurs Stud 2011; 48:1275.
  67. Egenberg S, Masenga G, Bru LE, et al. Impact of multi-professional, scenario-based training on postpartum hemorrhage in Tanzania: a quasi-experimental, pre- vs. post-intervention study. BMC Pregnancy Childbirth 2017; 17:287.
  68. Dijkman A, Huisman CM, Smit M, et al. Cardiac arrest in pregnancy: increasing use of perimortem caesarean section due to emergency skills training? BJOG 2010; 117:282.
  69. Fisher N, Eisen LA, Bayya JV, et al. Improved performance of maternal-fetal medicine staff after maternal cardiac arrest simulation-based training. Am J Obstet Gynecol 2011; 205:239.e1.
  70. Pittini R, Oepkes D, Macrury K, et al. Teaching invasive perinatal procedures: assessment of a high fidelity simulator-based curriculum. Ultrasound Obstet Gynecol 2002; 19:478.
  71. Deering S, Brown J, Hodor J, Satin AJ. Simulation training and resident performance of singleton vaginal breech delivery. Obstet Gynecol 2006; 107:86.
  72. Draycott T, Sibanda T, Owen L, et al. Does training in obstetric emergencies improve neonatal outcome? BJOG 2006; 113:177.
  73. Crofts JF, Bartlett C, Ellis D, et al. Management of shoulder dystocia: skill retention 6 and 12 months after training. Obstet Gynecol 2007; 110:1069.
  74. Szymanski L, Arnold C, Vaught AJ, et al. Implementation of a multicenter shoulder dystocia injury prevention program. Semin Perinatol 2017; 41:187.
  75. Clark SL, Simpson KR, Knox GE, Garite TJ. Oxytocin: new perspectives on an old drug. Am J Obstet Gynecol 2009; 200:35.e1.
  76. Hayes EJ, Weinstein L. Improving patient safety and uniformity of care by a standardized regimen for the use of oxytocin. Am J Obstet Gynecol 2008; 198:622.e1.
  77. Miller LA. Oxytocin, excessive uterine activity, and patient safety: time for a collaborative approach. J Perinat Neonatal Nurs 2009; 23:52.
  78. Simpson KR, Knox GE. Oxytocin as a high-alert medication: implications for perinatal patient safety. MCN Am J Matern Child Nurs 2009; 34:8.
  79. Clark S, Belfort M, Saade G, et al. Implementation of a conservative checklist-based protocol for oxytocin administration: maternal and newborn outcomes. Am J Obstet Gynecol 2007; 197:480.e1.
  80. Clark SL, Belfort MA, Byrum SL, et al. Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety. Am J Obstet Gynecol 2008; 199:105.e1.
  81. Clark SL, Meyers JA, Frye DK, Perlin JA. Patient safety in obstetrics--the Hospital Corporation of America experience. Am J Obstet Gynecol 2011; 204:283.
  82. Sundin C, Mazac L, Ellis K, Garbo C. Implementation of an Oxytocin Checklist to Improve Clinical Outcomes. MCN Am J Matern Child Nurs 2018; 43:133.
  83. Rohn AE, Bastek JA, Sammel MD, et al. Unintended clinical consequences of the implementation of a checklist-based, low-dose oxytocin protocol. Am J Perinatol 2015; 32:371.
  84. Vitner D, Lipworth H, Weiner E, et al. The effect of the implementation of institutional checklist on expert opinion of oxytocin use in labor. Arch Gynecol Obstet 2020; 302:127.
  85. Donovan EF, Lannon C, Bailit J, et al. A statewide initiative to reduce inappropriate scheduled births at 36(0/7)-38(6/7) weeks' gestation. Am J Obstet Gynecol 2010; 202:243.e1.
  86. Hirsch E, Haney EI, Gordon TE, Silver RK. Reducing high-order perineal laceration during operative vaginal delivery. Am J Obstet Gynecol 2008; 198:668.e1.
  87. Skupski DW, Lowenwirt IP, Weinbaum FI, et al. Improving hospital systems for the care of women with major obstetric hemorrhage. Obstet Gynecol 2006; 107:977.
  88. Rizvi F, Mackey R, Barrett T, et al. Successful reduction of massive postpartum haemorrhage by use of guidelines and staff education. BJOG 2004; 111:495.
  89. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med 2006; 144:742.
  90. Umar A, Ameh CA, Muriithi F, Mathai M. Early warning systems in obstetrics: A systematic literature review. PLoS One 2019; 14:e0217864.
  91. Pronovost PJ, Weast B, Rosenstein B, et al. Implementing and Validating a Comprehensive Unit-Based Safety Program. J Patient Saf 2005; 1:33.
  92. Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in Michigan. J Crit Care 2008; 23:207.
  93. Timmel J, Kent PS, Holzmueller CG, et al. Impact of the Comprehensive Unit-based Safety Program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf 2010; 36:252.
  94. Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety. Resident duty hours: enhancing sleep, supervision, and safety. National Academies Press, Washington, DC 2008.
  95. Kelly A, Marks F, Westhoff C, Rosen M. The effect of the New York State restrictions on resident work hours. Obstet Gynecol 1991; 78:468.
  96. Bailit JL, Weisberger A, Knotek J. Resident job satisfaction and quality of life before and after work hour reform. J Reprod Med 2005; 50:649.
  97. Espey E, Ogburn T, Puscheck E. Impact of duty hour limitations on resident and student education in obstetrics and gynecology. J Reprod Med 2007; 52:345.
  98. Bailit JL, Blanchard MH. The effect of house staff working hours on the quality of obstetric and gynecologic care. Obstet Gynecol 2004; 103:613.
  99. Hutter MM, Kellogg KC, Ferguson CM, et al. The impact of the 80-hour resident workweek on surgical residents and attending surgeons. Ann Surg 2006; 243:864.
  100. de Virgilio C, Yaghoubian A, Lewis RJ, et al. The 80-hour resident workweek does not adversely affect patient outcomes or resident education. Curr Surg 2006; 63:435.
  101. Salim A, Teixeira PG, Chan L, et al. Impact of the 80-hour workweek on patient care at a level I trauma center. Arch Surg 2007; 142:708.
  102. Liu BJ, Ordon M, Bodley J, et al. Impact of Resident Overnight Duty Hour Changes on Obstetrical Outcomes: A Population-Based Cohort Study. J Obstet Gynaecol Can 2018; 40:1586.
  103. Smrtka MP, Gunatilake RP, Harris B, et al. Increase in Cesarean Operative Time Following Institution of the 80-Hour Workweek. J Grad Med Educ 2015; 7:369.
Topic 4463 Version 28.0

References

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟