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Enhancing Maternal Care in the U.S.

In light of World Patient Safety Day, the urgency to enhance maternal care has become a focal point in healthcare discussions across the United States. Recent data from ECRI reveals troubling trends in maternal mortality rates, highlighting the need for immediate actions to ensure the safety and well-being of both mothers and newborns.

Persistent Challenge: Rising Maternal Mortality

As of 2024, the Centers for Disease Control and Prevention (CDC) reported that the U.S. witnessed 19 maternal deaths for every 100,000 live births, marking a troubling increase from previous years. The World Health Organization (WHO) cited the U.S. as one of the few nations experiencing a significant rise in maternal mortality over the past two decades. This alarming statistic churns in the foreground as healthcare providers and policymakers reassess their strategies in maternal care.

ECRI's Safety Sprint Initiative

To tackle these pressing issues, ECRI launched a safety sprint in collaboration with the Institute for Safe Medication Practices Patient Safety Organization (ISMP PSO). This initiative is designed to equip healthcare providers with best practices for ensuring safe transitions in maternal care, particularly when patients are moved between different care settings or providers. The program emphasizes the development of actionable plans and progress tracking through a collaborative learning system, significantly enhancing the approach to maternal care.

Insights from Data Analysis

ECRI’s data analysis, drawn from the largest dataset of its kind in the U.S. with over 7 million safety events, has uncovered vital information about the causes of patient harm in maternal care. In total, they analyzed 25,793 perinatal safety events from the year 2023, isolating 310 relevant incidents for further investigation. Shockingly, nearly half of these events involved unforeseen medical emergencies such as hemorrhage, eclampsia, and shoulder dystocia, which threaten the health of both mothers and their newborns.

The analysis pointed out the three primary contributors to safety events: communication and hand-off issues during transitions, pre-existing medical conditions, and delayed responses from care teams regarding concerning symptoms. Most incidents transpired during the crucial transition between labor and delivery or when moving to operating rooms, underscoring the need for systemic improvements in communication and care coordination.

Key Insights and Strategies for Improvement

ECRI's findings offer several key takeaways for healthcare leaders:

1. Pain Management Matters: Uncontrolled pain often signals imminent issues during labor and delivery, necessitating proactive management to mitigate risks.

2. Identifying Root Causes: An astonishing 42% of root cause analyses (RCAs) revealed no root causes, suggesting healthcare organizations may regard many adverse events as unavoidable. Organizations must focus on identifying contributing factors to enhance preparedness and response strategies during emergencies.

3. System-Wide Response Emphasis: Maternal health events can stem from various care settings. Therefore, readiness for potential complications should be part of a comprehensive care approach, including conducting regular risk assessments and drills, ensuring availability of necessary supplies, and fostering a culture of preparedness across all medical facilities.

Addressing Communication Gaps

The significance of patient transitions in maternal care cannot be overstated. Miscommunication or delays in crucial patient information can endanger maternal health outcomes. Ensuring accurate and timely communication of patient history and clinical conditions among healthcare providers will be critical in mitigating risks associated with care transitions.

Resources for Enhancing Maternal Care

In response to World Patient Safety Day, ECRI has made available numerous tools to aid healthcare organizations in improving maternal care, such as:

• - Maternal Health Driver Diagram
• - Improvement Plan Templates
• - Best Practices in Postpartum Care and Fetal Monitoring

ECRI is also committed to maternal health safety within federally qualified health centers, providing resources and education to promote better outcomes in these underserved regions.

Conclusion

Given the current circumstances surrounding maternal health in the United States, a dedicated effort toward improving care quality, safety, and communication is paramount. ECRI's robust data analysis and resource offerings serve as vital tools for healthcare providers aiming to mitigate risks and enhance maternal care services. The well-being of mothers and newborns hinges on our collective commitment to refine and prioritize this critical aspect of healthcare. For more information, healthcare professionals are encouraged to download the Patient Safety Event Data Snapshot for Maternal Health for further insights and strategies.