What’s New in the Patient Safety World

Joint Commission Sentinel Event Alert on Maternal Deaths


The Joint Commission has issued a new sentinel event alert “Preventing Maternal Death”, pointing out that maternal mortality rates may be increasing. Previous studies have shown that hemorrhage, complications of hypertension, pulmonary embolism, amniotic fluid embolism, infection, and pre-existing conditions are the major causes of maternal mortality. Black women, older women, and women who lack prenatal care are at greater risk of dying during pregnancy. The rise in the prevalence of obesity and its complications may be making coexisting medical conditions more important in leading to morbidity and mortality. They also note that significant morbidity is 50 times more common than mortality.


They cite studies putting the percentage of preventable maternal deaths at between 28 and 50%. Prior studies of preventable maternal deaths have identified issues such as inadequate attention to blood pressure management, inadequate management of pre-eclampsia, inadequate attention to vital signs after C-section, hemorrhage after C-section, and pulmonary embolism.


Some hospital systems have begun universal use of pneumatic compression stockings for all women undergoing C-section. Joint Commission makes this one of their recommendations and also suggests that low-molecular weight heparin prophylaxis be considered women at high risk for VTE in the post-partum period.


This sentinel event alert also discusses the importance of recognition of clinical deterioration in patients, an issue we have discussed in detail in our December 29, 2009 Patient Safety Tip of the Week “Recognizing Deteriorating Patients”. In addition to establishing triggers that should lead to immediate attention to maternal status, they recommend having staff run drills on how to respond to various types of clinical deterioration.


The December 2009 issue of the Pennsylvania Patient Safety Advisory has a great series of articles pertaining to patient safety in obstetrics. They provide a listing of all the maternal complications reported to the PPSRS over a 5-year period plus an excellent review of medication errors in labor and delivery with recommendations for reducing maternal and fetal harm.





The Joint Commission. Sentinel Event Alert. Issue 44, January 26, 2010

Preventing Maternal Death




Pennsylvania Patient Safety Authority. Pennsylvania Patient Safety Advisory. December 2009
















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