Perinatal Safety: Moving to Zero Harm. Allen Perinatal Team. Dr. Jeffrey Crandall Executive Sponsor Opens doors, improves patient outcomes, and acts as liaison between perinatal team and Allen Board. . Lori Murphy-Stokes RN MA Director Maternal-Child Services Team Leader
Moving to Zero Harm
Dr. Jeffrey Crandall
Opens doors, improves patient outcomes, and acts as liaison between perinatal team and Allen Board.
Lori Murphy-Stokes RN MA
Director Maternal-Child Services
Directs team meetings, coordinates resources, keeps team focused on Charter.
Theresa Pagel RN
OB Nurse Manager
Coordinates improvement activities with staff and providers.
Dr. Publio Ortiz
Liaison between team and providers. Assists evidence based practice changes.
Dr. Michelle Graham
Lori Hanson CNM.
Karen Storey RN OB QI
Data analysis, report writer.
Sarah Eiklenborg BSN
Marilyn Owusu RN
Milda Mullesch RN
Director of Case Management
Our story starts in September 2006. IHS joined the IHI initiative for improving patient care through evidence based practice.
We began with the White Paper for Pitocin induction and augmentation bundles. At that time we also wanted to know what our baseline for perinatal harm was, so we could document improvement. We began using the Perinatal trigger tool.
5 charts each week for Induction and 5 charts each week for Augmentation abstracted for the bundle elements.
The results were shared with the IHS perinatal team.
The IHS perinatal team met monthly on phone conferences. This is where ideas, questions, successes, failures, problems, and barriers were discussed. New ideas put foreword for consideration and trial.
Changed from Composite to All/None Score
The perinatal teams surveyed staff and providers regarding the culture of safety on the OB unit.
Allen’s results were:
5 maximum score achievable.
20 random charts reviewed per month. Triggers don’t necessarily mean an event happened. Must look for level of harm.
Perinatal Trigger Tool
Perinatal Trigger tool consists of the following Interventions:
7. -Ephedrine audit done and shared with Anesthesia.
8 - Ephedrine audit done and shared with Anesthesia.
9 - Iowa Perinatal Team visit.
10- Version 2 of induction of labor form and C/Sections implemented. Providers education done.
11- Pitocin bundle fallouts and perinatal team progress shared with providers at OB Committee meeting.
12- Perinatal team progress shared at OB Committee meeting.
13- Ephedrine audit results shared with Anesthesia.
14 -Vacuum bundle elements discussed with OB Committee need to come to agreement of Allen Providers standard documentation for operative deliveries.
15- Iowa Perinatal Team visit.
16- Ephedrine audit requested by anesthesia and results shared.
17- Documentation elements of vacuum bundle agreed upon by providers. Start abstraction of 100% vacuum assisted deliveries for compliance.
18- Pitocin bundle fallouts, Vacuum bundle fallouts, and perinatal team progress shared with providers at all OB Committee meetings. Individual providers contacted and informed of specific fallouts.
19 – Pitocin bundle fallouts, Vacuum bundle fallouts, and perinatal team progress shared with providers at all OB Committee meetings. Individual providers contacted and informed of specific fallouts.