The Institute of Medicines report, “To Err is Human: Building a Safer Health System” presented in 2000 sent a strong message about the need to promote a safe clinical environment. In the past several years there has been a great deal published in the obstetrical literature about creating a culture of patient safety.
- Failure to recognize fetal distress or nonreassuring fetal status
- Failure to effect a timely cesarean section
- Failure to properly resuscitate a depressed baby
- Inappropriate use of pitocin or cytotec
- Inappropriate use of forceps or vacuum
It was also suggested that if the characteristics of high reliability units in other industries were applied to perinatal care, recurrent sources of harm may successfully be addressed, and ultimately improve patient safety. (Knox, Simpson, and Townsend, 2003)
Characteristics of High Reliability Organizations How then can we prevent adverse outcomes in obstetrical units today? Some obstetrical units are considered low risk, related to patient injury and medical malpractice. What are the commonalities of certain obstetrical units that are able to manage risk and document positive patient outcomes? This does not happen by accident, rather these units display an organizational culture where patient safety is the number one priority and specific management and clinical practices are developed which help prevent neonatal and fetal injury. We have also observed that these units function in a way similar to those of other high risk industries, i.e. aviation. These high reliability organizations display the following characteristics:- Safety is #1 priority and it is each team member has equal responsibility for making this happen
- Team interactions are collegial rather than hierarchal
- Communication is valued and rewarded
- Emergencies are rehearsed
- Multidisciplinary reviews of the routine and debriefings of the unusual are arranged in order that normalization of deviance is prevented (Knox, Simpson, and Garite, 1999).
Characteristics of a High Reliability Obstetrical Unit
What are the characteristics that can be related to obstetrical units and perinatal practice that support the development of a high reliability perinatal unit? A unit that is committed to the delivery of safe care is one that utilizes the published national standards of ACOG and AWHONN. There is administrative and organizational support of clinical and administrative activities that prevent patient injury. Perinatal units are staffed appropriately, utilizing AAP/ACOG/AWHONN recommendations. Personnel trained in neonatal resuscitation are available and AAP guidelines are followed. There is a commitment to both teamwork and collegial relationships, and effective communication is valued. Emergencies are rehearsed, and drills are performed. There are clinical protocols and standardized orders are in place. Regular multidisciplinary reviews of both routine and unusual cases help prevent repeated acceptance of lowered performance standards (normalization of deviance). An interdisciplinary practice committee defines the policies of the unit. (Knox, Simpson, Townsend, 2003). Making it Happen How can you make improvements in your department? First there must be a “will”! Only when there is effort can there be lasting improvements; things cannot change unless we make them happen. Next we must utilize new ideas and leave behind the “status quo”. And last we must put these new ideas into practice and evaluate them to see if we have significantly improved patient outcomes and make necessary adjustments based on the evaluation. In this way we can create a culture of safety, adopting national standards as the foundation for clinical practice (Knox, Simpson, Townsend, 2003).
