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AHRQ Safety Program for Perinatal CareLabor and Delivery Unit SafetySlide 1SAY:The “Labor and Delivery Unit Safety” bundleprovides information on the key safetyelements concerning four specific situationsencountered in labor and delivery, and theimportance of a comprehensive unit-basedsafety approach to reduce the potential formaternal and neonatal harms.SAY:Slide 2In this presentation, we will do the following: Describe the rationale for the use ofchecklists for reducing errors.Identify the key safety elements for fourspecific situations encountered onlabor and delivery (L&D) units.Identify ways the key safety elementscan be customized for unit proceduresfor these four situations.SAY:Slide 3This bundle in the AHRQ Safety Program forPerinatal Care, or SPPC, focuses on keysafety elements for four specific L&Dsituations: Safe cesarean section Shoulder dystocia Obstetric hemorrhage Umbilical cord prolapseThe training materials and tools for this bundleoffer key safety elements for these situations,with a focus on the use of a checklist. Thesekey safety elements provide a starting point foreach unit to consider as it establishesprocesses for ensuring safe care. These keyAHRQ Publication No. 17-0003-21-EFMay 2017

Labor and Delivery Unit Safetysafety elements can also be adapted andapplied to other perinatal situations thatrequire high-reliability processes.SAY:Slide 4Care delivery varies greatly based onindividual provider training, providerinterpretation of evidence, their experience,and their preferences. Checklists help tofacilitate safety in high-complexity, high-risk,and high-reliability professions such asaviation, nuclear power plant operations, andnaval submarine crews. Hospitals can adoptchecklists to ensure the completion of criticalprocedures and processes within health caresettings.Cognitive psychology classifies tasks as eitherinvolving schematic behavior or attentionalbehavior. Schematic behavior includes tasksperformed reflexively or “on auto-pilot,”whereas attentional behavior requires activeplanning or problem solving. The types offailures resulting from these behaviors aredifferent. Errors associated with schematictasks are labeled “slips” and occur because oflapses in concentration, distractions, orfatigue. Errors associated with failures ofattentional behavior are labeled “mistakes”and often occur because of lack of experienceor insufficient training. Most errors in healthcare are slips rather than mistakes. Checklistsare cognitive aids that have numerouspractical benefits, including reducing slips thatoccur due to lapses in concentration,distractions, fatigue, or lack of knowledge ofevidence-based practices, because checklistsdecrease reliance on memory for taskstypically performed reflexively or “on autopilot.” Checklists can also provide confidencethat no step will be forgotten.AHRQ Safety Program for Perinatal CareL&D Unit Safety 2

Labor and Delivery Unit SafetySAY:Slide 5Simply giving a generic checklist to staff, orposting one on a rapid response cart or kit oron a wall is unlikely to be effective at reducingerrors.Checklist effectiveness for reducing errors canbe enhanced when— they are created or adapted to meetunit needsthey are implemented within a culturethat fosters teamwork andcommunicationstaff gain experience with them duringin situ simulation practiceSAY:Slide 6Each of the four tools in this bundle of theSPPC includes—the tool’s purpose;its intended use by nurses, physicians,midwives and other L&D staffresponsible for intrapartum care; key safety elements presented withinthe framework of the ComprehensiveUnit-based Safety Program, or CUSP;and a sample checklist or references orlinks to available checklists and othercognitive aids are provided for eachsituation.The key safety elements, sample checklists,and externally referenced checklists provide astarting point for each unit to consider asexamples for establishing safe processes forL&D unit safety. Units can customize, adapt, and tailor thespecific clinical guidance or instructions on thechecklist based on unit preferences, bestpractices, or emerging clinical evidence. Thesample checklists provided are examples ofhow key safety elements can beoperationalized in a checklist; they are notprovided as an endorsement of a specificclinical approach to management.AHRQ Safety Program for Perinatal CareL&D Unit Safety 3

Labor and Delivery Unit SafetySAY:Slide 7As in the other customizable bundles availablethrough the SPPC, the key safety elements forL&D unit safety are organized into sixoverarching principles of patient safety derivedfrom CUSP and the TeamSTEPPS teamworkand communication system. In thispresentation, the six principles are presentedby focusing first on situation-specific elementsrelated to these three principles: Standardize When Possible Create Independent Checks SimulationThis will be followed by the discussion of theother three principles that have a more generalapplication across all of the four perinatalsituations: Learn From DefectsTeamwork TrainingPatient and Family EngagementSAY:Slide 8First, we will highlight some of the key safetyelements from the tool for safe cesareansection.AHRQ Safety Program for Perinatal CareL&D Unit Safety 4

Labor and Delivery Unit SafetySAY:Slide 9The first consideration of L&D unit safety forsafe cesarean section is to standardize whenpossible.This is a core principle from the CUSPScience of Safety module. Standardizingprocedures reduces and alleviatesduplications of labor and resources, reducesunwarranted variation among providers andstaff, and offers a predictable approach thatencourages a shared mental model across theunit.The key safety elements focus on the use of astandard perioperative process that includes— Preoperative briefing Timeout SignoutStudies have found that the use of astandardized perioperative process with thesethree components reduces surgical mortalityand complications.5,6 This perioperativeprocess should be the standard approachused for ALL cesarean sections and shouldinclude— Involving all physicians and staffmembers engaged in the surgeryKnowing which member of the surgicalteam member is responsible forleading each step of the perioperativeprocessKnowing the defined roles for eachstaff member involved in the surgery toreduce variability from case to caseand create redundancy at critical stepsDefining acceptable variations in theperioperative process for emergencycesarean sectionsAHRQ Safety Program for Perinatal CareL&D Unit Safety 5

Labor and Delivery Unit SafetySlide 10SAY:The preoperative briefing reviews the planahead for patient care and the risks orconcerns so that everyone has a sharedmental model. It includes reviewing patientinformation, procedure, indications, anticipatedcomplications, risk, medical history, fetalstatus, and type of anesthesia. Theobstetrician/surgeon typically leads thepreoperative briefing. It allows him or her to“flatten the hierarchy” in the operating room,and encourage staff to speak up for safety ifthey see something they don’t think is right.Slide 11SAY: The timeout assures safety through a“huddle” or another checkpoint ofredundancy for each team member toagree with the plan and maternal andfetal status. The timeout is typically ledby the circulating nurse once all staffmembers are present in the operatingroom or OR.The signout and debrief provides astandard approach for wrapping up anddebriefing the case by reviewing whathas been done, the patient’s currentstatus, next steps, and what went well,what may have gone better or whatmight be done in the future, which isoften a moment for processimprovement. The signout is alsotypically led by the circulating nurse butmay be initiated by anyone on theteam.AHRQ Safety Program for Perinatal CareL&D Unit Safety 6

Labor and Delivery Unit SafetySlide 12SAY:The second consideration of L&D unit safetyfor safe cesarean section is to createindependent checks.This is also a core principle from the CUSPScience of Safety module. Independentchecks help guarantee the patient receives thehighest quality of care possible. Independentchecks can include checklists, protocols, andbriefings with other staff. L&D unit staff areable to focus on patient care and haveconfidence that untoward events (change inpatient condition, errors in dosing, etc.) will becaught by a check or team alert when itoccurs. The key safety element is to use achecklist to guide the safe surgeryperioperative process.Studies have found that checklist toolscan facilitate the three components of asafe perioperative process.3-6SAY:Slide 13A sample checklist, provided as anappendix to the tool, helps standardizethe perioperative process for cesareandeliveries.7 Use of a checklist mayprevent unnecessary surgicalcomplications and mortality. The checklistserves as a guide for teams by providingkey safety-related steps for apreoperative briefing, timeout, andsignout and debrief.Samples of the Safe Cesarean Checklistfor Planned/Routine Cesarean Sectionsare provided in two formats: an “at aglance” format or a “large print” format.The specific checklist items can becustomized based on unit preference.AHRQ Safety Program for Perinatal CareL&D Unit Safety 7

Labor and Delivery Unit SafetySAY:Slide 14The next consideration of L&D unit safety forsafe cesarean section is simulation.Team-based in situ simulation can improveknowledge, practical skills, communication,and team performance in acute situations.Several sample scenarios are availablethrough the SPPC can be used to train teamson the key perinatal safety elements related tosafe cesarean section.Any of the sample scenarios available throughthe SPPC that ultimately result in a team’sdecision to proceed to the OR for cesareansection delivery either emergently ornonemergently can be used.These scenarios reinforce teamwork andcommunication related to— situational awareness;efficient use of safe surgery checkliststo guide the perioperative processusing a perioperative briefing, timeout,and signout;communication with rapid responders;communicating with patient/family; andusing briefings, huddles, anddebriefingsSAY:Slide 15Now, let’s look at some of the key safetyelements from the tool related to care during adelivery complicated by shoulder dystocia.AHRQ Safety Program for Perinatal CareL&D Unit Safety 8

Labor and Delivery Unit SafetySAY:Slide 16The first consideration of L&D unit safety formanagement of shoulder dystocia is tostandardize when possible.The key safety elements focus on the use ofan established approach to managing anddocumenting episodes of shoulder dystociaand standardizing communication during anepisode. This approach can include— The care provider clearly stating theconcern for shoulder dystociaCommunication to others forassistance to put plan for safe deliveryinto place.Role designation of staff (e.g. recorder,patient/family communicator)Clinical maneuvers and directedmaternal pushing8,9Recording the time of dystociaidentification, and the time ofmaneuvers as performedEpisode documentation elements10Standardize communication using call outs11— to state concern for dystocia for fetal condition as each clinical maneuver is attempted for number of minutes that havepassed since diagnosisAHRQ Safety Program for Perinatal CareL&D Unit Safety 9

Labor and Delivery Unit SafetySAY:Slide 17The next consideration of L&D unit safety forshoulder dystocia management is to createindependent checks. Cognitive aids such as checklists,algorithms, or protocols may improveclinical team response andmanagement of shoulder dystocia.10,12-15– Such aids can provide clinicalteams with an independent checkon steps for facilitating a safedelivery by offering logic and aclear focus during what can oftenbe a chaotic event.– Such aids help teams have ashared mental model and efficientapproach for management anddocumentation during an episode.SAY:Slide 18A sample checklist for shoulder dystocia isprovided as an appendix to this tool. Itprovides suggested checklist items that teamscan use for safe care during an episode ofshoulder dystocia, and can also fosteraccurate and comprehensive documentation,which can be critical for a medical liabilitydefense. The specific checklist items can becustomized based on unit preference.Other sample checklists, algorithms,and protocols are also available.10,12-15AHRQ Safety Program for Perinatal CareL&D Unit Safety 10

Labor and Delivery Unit SafetySAY:Slide 19The next consideration of L&D unit safety forshoulder dystocia management is simulation.Studies have shown that simulation trainingcan improve clinician skills.13,16,17 A samplescenario is available through the SPPC to trainteams on the key perinatal safety elementsrelated to shoulder dystocia management.This scenario reinforces teamwork andcommunication related to—situational awareness,ability to get additional help quickly,use of cognitive aids, such aschecklists, communication with rapid responders, communication with patient/family, and use of briefings, huddles, anddebriefings.Shoulder dystocia simulation training focusedon clinical/technical skills may require amannequin or high-fidelity birthing simulator. SAY:Slide 20In this segment we will discuss some of thekey safety elements from the tool related toobstetric hemorrhage.AHRQ Safety Program for Perinatal CareL&D Unit Safety 11

Labor and Delivery Unit SafetySAY:Slide 21The first consideration of L&D unit safety formanagement of obstetric hemorrhage is tostandardize when possible.The key safety elements focus on ahemorrhage response protocol that provides astandardized approach to management andtimely treatment intensification for respondingto identified obstetric hemorrhages. Thisapproach can include— The use of routine and standardizedhemorrhage risk assessment onadmission.18-21o Individual risk factors predict someoccurrences of obstetrichemorrhage.o Risk assessments may include thepresence of clinical conditions thatincrease risk of hemorrhage, orpatient preferences that may limitthe use of blood and blood productsin the event of a hemorrhage.o Risk assessment can thendetermine the unit’s process forpatients based on level of risk, forexample different criteria for typeand hold, versus type and screen,versus type and cross, criteria forintravenous (IV) access, and needfor readily available specializedequipment (e.g., rapid volumeinfusers, cell saver technology).The use of standardized obstetrichemorrhage kits and carts. This allowsfor rapid access to pharmacologictherapy, such as uterotonics, and thesurgical equipment necessary torespond quickly to a hemorrhage.19,20The use of a standardized approach foractive management of the third stageof labor for vaginal births to preventhemorrhage.22-31o However, achieving unitwideagreement on the components of anactive management approach maybe challenging because of theavailable evidence about activeAHRQ Safety Program for Perinatal CareL&D Unit Safety 12

Labor and Delivery Unit Safetymanagement, differing values andopinions about the use of activeversus expectant management, andpatient preferences.o Consider using CUSP strategies togain consensus on a standardapproach that yields the moststandardization while still allowingflexibility for patient preferencesand/or where evidence is insufficientand variability in approach is unlikelyto increase risk of errors.SAY:Slide 22The next consideration of L&D unit safety forpostpartum hemorrhage management is tocreate independent checks. To reiterate, cognitive aids supportstandardization and a shared mentalmodel.Many externally developed examplesare available as part of perinatal safetyand quality initiatives of states orprofessional associations.18-20,26,32-35AHRQ Safety Program for Perinatal CareL&D Unit Safety 13

Labor and Delivery Unit SafetySAY:Slide 23Another element related to creatingindependent checks is to quantify blood lossduring all deliveries and during a hemorrhageepisode.Nonstandardized, informal, visual estimationmethods typically underestimate blood loss,resulting in delayed recognition andmanagement of obstetric hemorrhage.19,27,36-41Methods for quantifying blood loss may varyby type of delivery (vaginal or cesarean) buttypically involve quantifying blood lossbeginning immediately after birth of the infant,using calibrated under-buttocks drapes, directmeasurement of blood in collection containers,weighing blood blood-soaked objects toestimate volume, or using standardizedmethods of visual estimation.Resources for training staff to learnquantification methods are available.19,42-44SAY:Slide 24The next consideration is simulation.Two sample scenarios, available throughSPPC, can be used to train teams on the keyperinatal safety elements related to a teamapproach to obstetric hemorrhage. Thesescenarios, one for antepartum hemorrhageand one for postpartum hemorrhage, reinforceteamwork and communication related to—situational awareness;early identification of hemorrhagethrough quantification of blood loss; use of cognitive aids, such ashemorrhage flowsheets, algorithms,and protocols; communication with rapid responders; communicating with patient/family; and using briefings, huddles, anddebriefings.Several externally developed scenarios arealso available.45-51 AHRQ Safety Program for Perinatal CareL&D Unit Safety 14

Labor and Delivery Unit SafetySAY:Slide 25In this segment, we will discuss some of thekey safety elements from the tool related tocare during a delivery complicated by cordprolapse.SAY:Slide 26The first consideration of L&D unit safety forcord prolapse management is to standardizewhen possible.The key safety elements focus on a cordprolapse response protocol that uses a unitapproved predetermined approach, andstandard communication of information tomanage a cord prolapse. This approach caninclude— staff who identify a possible prolapseand call out the concern;communication to others for assistanceto put plan for safe delivery intoplace52;role designation of staff (e.g., recorder,patient/family communicator);appropriate clinical interventions;recording of time of prolapseidentification, and time of interventionsperformed; andepisode documentation elements.AHRQ Safety Program for Perinatal CareL&D Unit Safety 15

Labor and Delivery Unit SafetySAY:Slide 27The next consideration of L&D unit safety forcord prolapse management is to createindependent checks.Staff can increase situational awareness byusing cognitive aids, such as checklists, ofmaternal and fetal criteria for procedures thatincrease risk for cord prolapse53 such as—amniotomyintrauterine pressure catheter or fetalscalp electrode placement manual rotation placement of cervical balloon catheter external cephalic version amnioinfusion placement of forceps or vacuumCognitive aids such as checklists, algorithms,or protocols, may improve team response tocord prolapse.54-57 SAY: Slide 28A sample cord prolapse managementand documentation checklist isprovided as an appendix to this tool.This sample provides suggestedchecklist items for safe care during adelivery complicated by cord prolapse.It can also foster accurate andcomprehensive documentation, whichcan be critical for a medical liabilitydefense. Although the steps in thesample checklist are presented insequential order; this is done to ensurethat no steps are missed rather than todictate a rigid sequence of events. TheL&D team should use its clinicaljudgment and evidence-basedpractices to determine the order ofsteps. In practice, steps listed may notoccur sequentially.The checklist items can be customizedbased on unit preference. Otherexample checklists, algorithms, andprotocols are also available.54-56AHRQ Safety Program for Perinatal CareL&D Unit Safety 16

Labor and Delivery Unit SafetySAY:Slide 29The next consideration of L&D Unit Safety forcord prolapse management is simulation.A sample scenario, available through SPPC,can be used to train teams on the keyperinatal safety elements related to a teamapproach to cord prolapse. This scenarioreinforces—situational awareness,ability to get additional help quickly,efficient use of cognitive aids, such aschecklists, communication with rapid responders, communicating with patient/family, and using briefings, huddles, anddebriefings.Cord prolapse simulation training focused onclinical/technical skills may require amannequin or high-fidelity birthing simulator. Now let’s focus on the remaining three keysafety elements with more general applicationincluded in each of the tools: Slide 30learn from defects,teamwork training, andpatient and family engagement.AHRQ Safety Program for Perinatal CareL&D Unit Safety 17

Labor and Delivery Unit SafetySAY:Slide 31Key perinatal safety elements around learnfrom defects include— Fostering a culture that supportsdebriefing by the clinical teamimmediately after a near miss, anadverse event, or an otherwisecomplex episode of care.o A unit can decide its approach todebriefing events based on theseriousness of the event,expertise available, and datamonitoring and trackingcapabilities.Having a process in place to reviewsevere maternal or neonatal morbidityand mortality events.o A unit can decide its approach butthis review might include anexisting medical peer reviewprocess or review by a perinatalsafety or quality committee.Share outcomes or processimprovements from informaldebriefings and formal analyses withstaff to achieve transparency andorganizational learning.AHRQ Safety Program for Perinatal CareL&D Unit Safety 18

Labor and Delivery Unit SafetySAY:Slide 32The fifth consideration is teamwork training.This aspect of perinatal safety calls for L&Dunits to foster a culture of teamwork andcommunication to promote effective teamwork.TeamSTEPPS teamwork training offersseveral useful communication techniques.These include— Having situational awareness aboutmaternal and fetal risks and status.This includes staff alertness for issuesthat raise maternal or fetal risk and forearly signs of fetal or maternal distress,and knowing the plan for a timelyresponse to prevent furtherdeterioration.Using SBAR (Situation, Background,Assessment, and Recommendation),callouts, huddles, and closed-loopcommunication among team members.These are useful for communicating asense of urgency when requesting helpresponding to sudden changes inmaternal or fetal status, and for briefingnew care team members as they arriveto assist, and give or receive orders.Communicating during transitions ofcare helps to assure a shared mentalmodel of the plan of care andperceived risks between shifts,between units, or between individualswithin the same unit.Having high-reliability teams meansthat anyone can sound an alarm,request help, or challenge the statusquo; hierarchy is minimized; andcommunication is continuous, valued,and expected.AHRQ Safety Program for Perinatal CareL&D Unit Safety 19

Labor and Delivery Unit SafetySAY:Slide 33The final consideration is patient and familyengagement.The key safety elements are as follows: SAY:Communicating and educating patientsand families around the clinicalprocesses involved during episodes toensure a shared mental model with thepatient and family as well as the clinicalteam. This may include assigning astaff member to communicate with thefamily during the response, andproviding ongoing reassurance.Likewise, a unit must be ready todisclose any unintended outcomes.Unit-established process for disclosingunintended outcomes may include thefollowing:o Prompt, compassionate, andhonest communication with thepatient and familyo Investigationo Ongoing communication with thepatient and familyo Apology and remediationo System and processimprovemento Measurement and evaluationo Education and trainingSlide 34Key perinatal safety elements, samplechecklists, and externally available examplescan be used to develop the unit’s specificapproaches to safe cesarean section, shoulderdystocia, obstetric hemorrhage, and cordprolapse. Review the key safety elements withL&D leadership and relevant staffDetermine how the elements will becustomized for the unit.Consider any existing hospitalprocedures, policies, processes relatedto these four situations.Review the sample checklists andmodify or build content to fit withexisting documentation systems.AHRQ Safety Program for Perinatal CareL&D Unit Safety 20

Labor and Delivery Unit SafetySAY:Slide 35The next steps are to— Decide whether to select componentsof the Labor and Delivery Unit Safetybundle for implementation locally.Factors to consider—o Unit and malpractice claims datasuggesting adverse events or nearmisses related to cesarean section,shoulder dystocia, postpartumhemorrhage, or cord prolapseo Synergy with related or similarinitiativeso Interest and enthusiasm of unit stafffor implementingSupport implementation of unitprocedure with—o staff training and communicationando use of simulations.Monitor implementation progress andimpact with data.SAY:Slide 36Here are some tips for implementing toolssuccessfully: Use CUSP principles for implementingteamwork and communication (e.g.,incorporating diverse perspectives) todevelop consensus on the “clinicalcontent” of the L&D Unit Safety tools.Pilot test any new procedures to workout any bugs or problems.Comprehensively review unitprocedures each year to assess theneed for updates to ensure content isup to date.Create a mechanism for identifyingrecurrent nonuse or deviation from theestablished procedure by clinicians.Seek to understand why, rather thanassign blame.AHRQ Safety Program for Perinatal CareL&D Unit Safety 21

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the tool's purpose; its intended use by nurses, physicians, midwives and other L&D staff responsible for intrapartum care; key safety elements presented within