Joch A. New era of preventing birth-related deaths. Materials Management in Health Care. July 2008.

Maureen Bisognano, Executive Vice President and COO of the Institute for Healthcare Improvement, talks about the Premier initiative to formalize care practices to eliminate preventable birth-related injuries and deaths. Best practices that have shown encouraging results in smaller-scale efforts at individual hospitals are also discussed.

Connolly K. Reducing harm to infants during labor and delivery. Biomedical Instrumentation and Technology. 2007;Suppl:60-4.

The work to date of the Perinatal Innovation Workgroup — a collaboration of the Institute for Healthcare Improvement, Ascension Health of St. Louis, and Premier, Inc. and its member hospitals — recommends that perinatal care bundles be used when deciding whether to induce labor electively and for managing labor that is not progressing. The project was initiated to change obstetric health care delivery so that fewer infants are harmed during the delivery process and that costs from avoidable medical errors.

Mazza F, Kitchens J, Kerr S, Markovich A, Best M, Sparkman LP. Eliminating birth trauma at Ascension Health. Joint Commission Journal on Quality and Patient Safety. 2007 Jan;33(1):15-24.

Ascension Health identified perinatal safety as one of eight priorities for action in a system-wide effort to achieve zero preventable injuries and deaths by July 2008. Three alpha sites developed and implemented transformational practices aimed at eliminating preventable birth trauma.

Rubin R. New moms and newborns need privacy, study shows. USA TODAY. December 4, 2006.

A study in the latest Journal of Obstetric, Gynecologic, and Neonatal Nursing found that women typically experienced dozens of interruptions during their first day after delivering a baby when new moms and babies need to breast-feed frequently. This article describes what some hospitals working with the Institute for Healthcare Improvement are doing to improve the care of mothers and newborns during the perinatal period.

Sharek PJ, Horbar JD, Mason W, et al. Adverse events in the neonatal intensive care unit: Development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs. Pediatrics. 2006 Oct;118(4):1332-1340.

This article discusses the use of a NICU-focused tool for adverse event detection and describes the incidence of adverse events in NICUs identified by this tool. The authors found that adverse event rates in the NICU setting are substantially higher than previously described and the majority are preventable. They concluded that the NICU-focused trigger tool appears efficient and effective at identifying adverse events.

Holden J. Safer perintal care: Institute for Healthcare Improvement's plan outlines best practices. Advance for Nurses (online edition). 2006 July 17;8(16):24.

This article provides an overview of the Institute for Healthcare Improvement's (IHI's) work to provide safer perinatal care, as described in IHI's white paper Idealized Design of Perinatal Care. The new design incorporates culture change, improved communication, and use of evidence-based intervention "bundles," among other things.

Simpson KR. Measuring perinatal patient safety: Review of current methods. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 2006 May-Jun;35(3):432-442.

This article presents a review of current structure, process, and outcome measures currently being used in perinatal safety efforts, as well as a review of safety climate attitude surveys and questionnaires. The author recommends the use of accurate and timely data feedback to improve current initiatives in perinatal safety.

Thorman KE, Capitulo KL, Dubow J, Hanold K, Noonan M, Wehmeyer J. Perinatal patient safety from the perspective of nurse executives: A round table discussion. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 2006 May-Jun;35(3):409-416.

Nurse executives across the US discussed issues related to perinatal patient safety and identified key issues. Their recommendations included using face-to-face communication, developing an interdisciplinary practice committee, standardizing terminology for electronic fetal heart rate monitoring, using role playing and drills to help team members remain calm, and creating a confidential non-punitive mechanism for reporting.

Haig KM, Sutton S, Whittington J. SBAR: A shared mental model for improving communication between clinicians. Joint Commission Journal on Quality and Patient Safety. Mar 2006;32(3):167-175.

The importance of sharing a common mental model in communication prompted efforts to spread the use of the SBAR (Situation, Background, Assessment, and Recommendation) tool at OSF St. Joseph Medical Center in Bloomington, Illinois.

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Simpson KR. Measuring perinatal patient safety: Review of current methods. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 2006 May-June;35(3):432-442.

A balanced set of patient safety measures provides valuable and timely data and feedback to caregivers to guide efforts to improve perinatal patient safety. Methods to measure patient safety include structure, process and outcome measures, safety attitude and climate surveys, focus groups, storytelling, executive walk rounds, and external review.