I'll never forget that day. I was early in my career as a labor and delivery nurse when a tragedy occurred that is still fresh in my memory. In the mid-1980s, fetal heart rate monitors were big, bulky machines and were difficult to transport. A mother was in labor with her second child and delivery was imminent. The doctor requested we move her to the delivery room. We decided there was no need to bring the monitor for the three-minute move; the mother could be reattached to the monitor in the delivery room.
In the few minutes it took us to transport the mother, her baby descended quickly, tightening a knot in the umbilical cord. The baby suffered anoxia and later died. The mother was devastated and wanted to know how something like this could have happened.
At Ascension Health, the nation’s largest Roman Catholic and not-for-profit healthcare system, we are guided by the principle that we must continuously seek to reduce and eliminate preventable injuries and deaths. Our initiatives have had remarkable results for our patients—we have lowered rates of preventable injuries to below national averages in a number of areas including mortality and pressure ulcers.
Last fall, we began a program that I am confident will help reduce rates of preventable birth trauma to the lowest levels possible.
With funds from the Agency for Healthcare Research and Quality, under its patient safety and medical liability initiative, we launched Excellence in Obstetrics at five Ascension sites. Our project goals are to improve patient safety in the birthing process, prepare expert birthing teams to handle crisis events rapidly, and change how medical liability is managed if a serious safety event occurs.
The issues we are addressing through Excellence in Obstetrics are essential questions all hospitals should ask: How can we prevent serious safety events? How can we ensure transparency when tragedies occur so families and doctors better understand what could have happened differently? And, how can we improve our system of medical liability to provide fair and just compensation if a mistake occurs, yet avoid frivolous lawsuits?
By studying the medical records of consenting mothers, we hope to provide insight into these questions from which all hospitals—even beyond Ascension Health—may learn. Also, the lessons learned could be spread to other high-risk areas of hospitals, including the emergency department and operating room.
My colleague Dr. Paul Burstein’s recent experience sums up the value of this study. Burstein is a practicing obstetrician and physician site lead for the AHRQ study at 177-bed Columbia St. Mary’s hospital in Milwaukee. His patient, Jill, was in labor when her baby’s heart rate dropped. Paul discussed the options for delivery with Jill and together they opted for an emergency cesarean section. Upon delivery, Paul discovered an occult prolapse and tight nuchal cord, which could have led to a very different outcome.
Both doctor and patient credit the teamwork in the operating room as instrumental in the success of the delivery. Jill’s story illustrates the impact of this project on an individual level. Imagine what the impact will be as these learnings are shared across the country.
Each of us must be committed to building a high-reliability healthcare organization. We can’t undo unanticipated outcomes, but we can do the right thing by treating the patient and family with holistic, reverent care through open communication. And, most important, we can work to assure that if the unanticipated outcome was caused by an error, the same failure modes that contributed to the event are not repeated.
Ann Hendrich is vice president of clinical excellence operations for Ascension Health, St. Louis, and a principal investigator for the Agency for Healthcare Research and Quality.