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Multidisciplinary Severe Maternal Morbidity Reviews Can Teach the Clinical Learning Environment Review Focus Areas of Patient Safety and Quality

Purpose: To describe a resident focused multidisciplinary severe maternal morbidity (SMM) review program.

 

Background: The Joint Commission defined SMM as peri-partum blood transfusion of 4 units or admission to ICU and recommends multidisciplinary reviews to determine opportunities for improvement in care

 

Methods: An ongoing process detects cases of SMM with root-cause-analysis performed if case qualifies as a sentinel event. Data is extract and presented quarterly to, a multidisciplinary committee to determine contributory factors, opportunities to alter outcome, best practices and recommendations.

 

Results: Forty-five SMM cases were reviewed from 1/15 to 6/17 by residents 67%, fellows 9%, nurses 7%, and MFM faculty 17%. Opportunities to alter care were determined to be strong in 9% and possible in 62%. System/provider   could alter outcome in 53% while the patient could have altered outcome in 33% of cases.  Outcomes could have been altered by contraception/sterilization in 13%, patient compliance 11%, early prenatal care 20%, referral/consultations 9%, improved documentation 7%, early recognition 33%, team communication 4% and management 31%. Good practices recognized included multidisciplinary teamwork/communication 60%, evidence-based response 36%, timely recognition 24%, documentation 20%, quality obstetric care 22%, timely referral 13%, expertise care 9%, and patient-centered-care 7%. Strong opportunity to alter outcome was present with hypertensive crisis (p=0.026). Significant opportunities to alter outcomes were: preterm SMM cases by contraception/sterilization (p=0.036); patient compliance in Medicaid insured (p=0.01) and younger women (p=0.04). Transfusions were recognized for the good practice of timely recognition (p=0.045).

 

Discussions: Residents’ involvement in SMM reviews can determine care improvement opportunities and provide training on safety and quality.

Topics: CREOG & APGO Annual Meeting, 2018, Student, Resident, Faculty, Clerkship Director, Osteopathic Faculty, Residency Director, Residency Coordinator, Patient Care, Medical Knowledge, Professionalism, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, GME, Quality & Safety, Public Health, Maternal-Fetal Medicine,

General Information


Intended
Audience
Student,Resident,Faculty,Clerkship Director,Osteopathic Faculty,Residency Director,Residency Coordinator,
Competencies
Addressed
Patient Care,Medical Knowledge,Professionalism,Systems-Based Practice & Improvement,Interpersonal & Communication Skills,Practice-Based Learning & Improvement,
Educational
Continuum
GME,
Educational
Focus
Quality & Safety,Public Health,
Clinical Focus
Maternal-Fetal Medicine,

Author Information

Dotun Ogunyemi, MD

Beaumont Royal Oak

Natalie Hage, MD; Kim Sun, MD, PhD; and Perry Friedman, MD

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