Chair, Department of Obstetrics and
Gynecology; Obstetrician and
Medicine, NewYorkPresbyterian Hospital/Weill Cornell
Medical College
reduce the probability of human error; they accept that errors
identify their root cause, so that the deficiency is identified and cor-
rected. Once the problem is corrected, it is unlikely that the error will
recur, explained Dr. Chervenak.
States--in fact, there are data to suggest that they are the sixth-
leading cause. A 1999 Institute of Medicine report
patients--more than 1 million patients each year. More than half of
these adverse events could have been prevented; most are problems
resulting from systems errors, rather than individual error, the report
found.
NewYork-Presbyterian Hospital/Weill Cornell Medical College
seriously addressed this issue and made it a priority. It took a cue
from the airline industry, which has implemented
1970s through 2010, U.S. airline safety improved markedly due to
this training, with significant reductions in the number of fatal
accidents occurring, Dr. Chervenak noted.
on the Cornell Labor & Delivery unit in order to make it safer to
have a baby," Dr. Chervenak said of the work spearheaded at the
organization in conjunction with Amos Grunebaum, MD, professor of
clinical obstetrics and gynecology at Weill Cornell Medical College.
hospital a safer place for pregnant patients and is at the center of
many patient safety programs. Through an established program,
which is mandatory in most medical centers in the United States,
obstetrical units enhance their skills on how to function effectively as
a team. The four- to eight-hour course--repeated periodically to
maintain the skills and to update procedures the team utilizes with
new information--focuses on drills for such situations that are
critical events for both the mother and her baby. Events that can be
catastrophic include shoulder dystocia, peri- and postpartum bleeding/
hemorrhage, maternal cardiac arrest, and eclampsia. STAT Cesareans,
which also carry a high degree of morbidity and mortality for the baby,
are also simulated. This training is to ensure that all members of the
obstetrical team, including the obstetrician, nurse, anesthesiologist,
blood bank personnel, and neonatologist, know what their role is
during all obstetrical emergencies and how to address them in the
most timely fashion possible.
quickly, but there are also the everyday nurse-to-clinician interactions
that, although not necessitating stat care, rely on excellent communi-
cation, which is critical to the patient and her baby. For example, if a
nurse checks the blood pressure on a laboring patient and it is
extremely high, then the nurse must be sure the message gets quickly
to the obstetrician, and that both the systolic and diastolic values are
noted and understood by the obstetrician. As well, in order to confirm
an effective exchange of medical information, the obstetrician repeats
the blood pressure values back to the nurse. In this way, the loop for
excellent communication and care is closed.
or clinician caring for the patients ends a shift, it is extremely impor-
tant for each to communicate thoroughly what has been clinically
happening, what is pending (such as a blood test whose results are
still not back), and what the clinical plans are at that point. Never
should any of the health care team leave the hospital after their shift
without communicating the status of the patient.
tenet that everyone on the team (the nurse, learner, or any other
team member) is empowered to report and follow through on issues
that they note are negatively contributing to the patient and the
desired health outcome. By everyone on the team being able to voice
are working in systems that need to be
made safer." Team training and systemic
changes in obstetrical procedures can have
a significant impact on improving
maternal safety and reducing liability
due to medical errors.