Room for Improvement: Safety Initiative Cuts Birth Injury Rates

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The first results of a two-year perinatal safety initiative shows that better hospital practices can sharply reduce many preventable birth injuries. By finding that hospitals can avoid as many as 30 percent of these injuries, the study shows that Ohio can make big progress in the near future. Given the potentially severe consequences of birth injuries, there is no excuse for failing to implement similar strategies at hospitals around the country.

This initiative occurred across 14 hospitals, including several here in Ohio. Beginning in 2008, the program used two main tools to reduce birthing injuries by between 5.4 and 25 percent in the participating hospitals.

One tool was improved teamwork and communication across different caregiving roles. Surprisingly, the study attributed 70 percent of “sentinel events” to poor communication. By implementing team training scenarios, simulated exercises and communication protocols developed by the armed forces, these hospitals were able to make clear, demonstrable improvements.

The initiative referred to its second central tool as “evidence-based care bundles.” These “bundles” bring different treatment steps and processes together into one checklist or procedure. This helps caregivers do a better job of remembering to work through every component – reducing the chances of a nurse or doctor making a potentially catastrophic mistake.

While these results are certainly grounds for optimism about the future, the initiative also shows some of the unacceptable ways in which preventable problems turn into serious injuries. The fact that “care bundles” were such a core tool for reducing birth injuries is particularly disturbing – it shows that caregiver inattentiveness contributes to far too many of these cases.

Source: Premier, “Premier Perinatal Safety Initiative Phase I Summary 2008 – 2010,” Dec. 2012

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