A January 2010 Sentinel Alert published by the Joint Commission finds that hospital errors are causing up to half of pregnancy-related maternal deaths - and the problem is increasing. The alert finds that the most common errors include the following:
- Failure to adequately control blood pressure in hypertensive women
- Failure to adequately diagnose and treat pulmonary edema in women with pre-eclampsia
- Failure to pay attention to vital signs following Cesarean section; and
- Hemorrhage following Cesarean section
Unfortunately, many hospitals fail to follow existing Joint Commission recommendations, such as The Provision of Care, Treatment and Services standard, PC.02.01.19, which require each hospital to:
- Have a process for recognizing and responding as soon as a patient’s condition appears to be worsening.
- Develop written criteria describing early warning signs of a change or deterioration in a patient’s condition and when to seek further assistance.
- Based on the hospital’s early warning criteria, have staff seek additional assistance when they have concerns about a patient’s condition.
- Inform the patient and family how to seek assistance when they have concerns about a patient’s condition.
As a result, the Joint Commission is asking hospitals to take the following actions:
Educate physicians and other clinicians who care for women with underlying medical conditions about the additional risks that could be imposed if pregnancy were added; how to discuss these risks with patients; the use of appropriate and acceptable contraception; and pre-conceptual care and counseling. Communicate identified pregnancy risks to all members of the health care delivery team.
Identify specific triggers for responding to changes in the mother’s vital signs and clinical condition and develop and use protocols and drills for responding to changes, such as hemorrhage and pre-eclampsia. Use the drills to train staff in the protocols, to refine local protocols, and to identify and fix systems problems that would prevent optimal care.
Educate emergency room personnel about the possibility that a woman, whatever her presenting symptoms, may be pregnant or may have recently been pregnant. Many maternal deaths occur before the woman is hospitalized or after she delivers and is discharged. These deaths may occur in another hospital, away from the woman’s usual prenatal or obstetric care givers. Knowledge of pregnancy may affect the diagnosis or appropriate treatment.
Additional suggested actions for hospitals and providers to take for patients identified as high-risk (for example, those with pre-existing medical conditions such as hypertension, diabetes, morbid obesity):
Refer high-risk patients to the care of experienced prenatal care providers with access to a broad range of specialized services.
Make pneumatic compression devices available for patients undergoing Cesarean section who are at high risk for pulmonary embolism. 6.
Evaluate patients who are at high risk for thromboembolism for low molecular weight heparin for postpartum care.