Why It Matters
Melissa’s Story*
Though she had a late postpartum hemorrhage that resulted in a hysterectomy and a transfusion of about 12 units of blood, Melissa Price, the patient representative on the California Maternal Quality Care Collaborative (CMCQCC) Hemorrhage Task Force, considers herself lucky. While in the Emergency Department, Melissa recalls asking how the health care team could tell how much blood she was losing. The blood was dumped from a bed pan into a portable toilet and was never weighed. After the team got the bleeding to stop, Melissa was left alone behind a curtain and checked on infrequently. When the bleeding started up again and she saw “enormous clots,” Melissa screamed. “I will never forget the look on the nurse’s face when she lifted up that blanket,” she recalls. The ED staff went into high alert. “They were running around everywhere,” she continues. “Rushing to call my obstetrician (OB). Rushing to get an OR suite. Rushing to figure out how to turn off my insulin pump.” Melissa started to pray. “I just kept thinking, ‘God give them more time. They need more time to save me.’” As she was being transported to the OR, her OB was running alongside her. “I grabbed his hand and said, ‘Get me to the other side of this.’ He said, ‘Melissa, I will do everything I can to get you there.’” To this day, she is haunted by the thought that — if she had fainted — she would not have been able to get her nurse’s attention. “Things would likely have turned out very, very differently,” she says.
There is a global maternal mortality (MM) — death during pregnancy, birth or within a year of birth — and severe maternal morbidity (SMM) — significant short-term or long-term consequences after birth — public health crisis. As of 2017, the global maternal mortality ratio was 211 deaths per 100,000 live births. The United States spends the highest percentage of its gross domestic product on health care (among 10 other high-income countries), yet the US ranks last in maternal mortality, with 17.3 deaths per 100,00 live births and about 700 birthing persons dying per year due to pregnancy related causes. However, SMM is more prevalent, as an estimated 70 women suffer from a severe complication for every maternal death.
Both SMM and MM are associated with a high rate of preventability (20-60 percent) after multidisciplinary team case review. An important factor to address is diagnostic safety, as it has been understudied in obstetrics and is an important potential contributor to SMM/MM. Diagnostic safety as defined by the National Academy of Sciences, Engineering, and Medicine (NASEM) is “the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.” Understanding diagnostic safety can contribute to decreasing these events.
The Importance of Diagnostic Safety
Diagnoses that are delayed, incorrect, or missed altogether been known to cause patient harm. For example, in Melissa’s Story, the diagnosis of postpartum hemorrhage was delayed and could have been improved by accurate assessment of blood loss and other clinical indicators of hypovolemia. A collaborative approach should be used to identify opportunities for risk reduction and develop a system for improving at-risk processes.
Addressing diagnostic safety is now being recognized as having an important role in obstetrics. Of the limited research on this subject, one study of the prevalence of diagnostic errors as predictors of obstetric outcomes in Kenya revealed that diagnostic errors often result in wrong interventions and that these occur at an alarming rate. In this study, failure to properly diagnose a condition contributed to 58 percent of errors in the emergency department that led to subsequent obstetric emergencies. The high mortality and morbidity in this region are mainly associated with delayed, missed, and wrong diagnoses. Another study of obstetric outcomes in the Philippines suggests that diagnostic error was associated with a three-fold likelihood of obstetric complication.
Recognizing diagnostic error in obstetrics as a problem in both developed and developing nations and identifying ways to better understand and address it will be critical to improving maternal outcomes. A recent Agency for Healthcare Research and Quality’s (AHRQ) Diagnostic Safety Issue Brief (“The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science”) highlights the contribution of diagnostic error to maternal morbidity and mortality, asserts the rationale for suggested improvement methods, and presents a research agenda necessary to make progress in this emerging area.
Using the 5 Rs to Apply a Diagnostic Safety Lens to Case Review
Multiple professional societies and related governing bodies have advocated for addressing maternal morbidity and mortality through the “4Rs”(Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning), and a newly added fifth domain, Respectful Care, that is critical for delivering safe, patient-centered, high-quality care:
- Readiness — The ability to use an institution’s resources, protocols, and procedures when needed
- Recognition — Assessment, measurement, and management
- Response — Treatment
- Reporting and System Learning — Communication, debrief, and review
- Respectful Care — Recognizing the patient’s right to be educated, informed, and supported
Table 1 — Using the 5 Rs to Review the Case Example and Opportunities for Improvement
| Readiness — The ability to use an institution’s resources, protocols, and procedures when needed |
From the case example: “While in the Emergency Department…” Opportunity for Improvement: ED team unfamiliar with OB hemorrhage Diagnostic Process Dimension: Patient-Provider Encounter & Initial Diagnostic Assessment Examples of improvement efforts underway:
|
| Recognition — Assessment, measurement, and management |
From the case example: “The blood was dumped from a bed pan into a portable toilet and was never weighed. After the team got the bleeding to stop, Melissa was left alone behind a curtain and checked on infrequently.” Opportunities for Improvement: · No quantification of actual blood loss · No repeated Quantified Blood Loss (QBL) until bleeding stopped Diagnostic Process Dimension: Diagnostic Test Performance & Interpretation Examples of improvement efforts underway:
|
| Response — Treatment |
From the case example: “[The ED staff] were running around everywhere. Rushing to call my OB. Rushing to get an OR suite. Rushing to figure out how to turn off my insulin pump.” Opportunities for Improvement: · OB consultation should be called in timely manner · Lack of standardized team approach Diagnostic Process Dimension: Subspecialty/Consultation Referral Issues Examples of improvement efforts underway: · Safety huddles to communicate re: critical patients · Emergency plan with checklists · TeamSTEPPS training to improve team communication · CUS Tool to encourage all staff to speak up re: patient safety |
| Reporting and System Learning — Communication, debrief, and review |
From the case example: “. . . she had a late postpartum hemorrhage that resulted in a hysterectomy and a transfusion of about 12 units of blood” Opportunities for Improvement: · Medical Termination of Pregnancy (MTP) Protocol enacted · Additional treatments? Diagnostic Process Dimension: Follow-Up & Tracking of Diagnostic Information Examples of improvement efforts underway: · Culture of post-hemorrhage debriefs and documentation · High-risk patients discussed & noted at briefings several times daily |
| Respectful Care — Recognizing the patient’s right to be educated, informed, and supported |
From the case example: “I will never forget the look on the nurse’s face when she lifted up that blanket. . . I just kept thinking, ‘God give them more time. They need more time to save me.’ I grabbed [my OB’s] hand and said, ‘Get me to the other side of this.’ He said, ‘Melissa, I will do everything I can to get you there.’ To this day, [Melissa] is haunted by the thought that — if she had fainted — she would not have been able to get her nurse’s attention. “Things would likely have turned out very, very differently.” Opportunities for Improvement: · Being patient-centered · Supporting staff through emotional and psychological trauma Diagnostic Process Dimension: Patient-Related Factors Examples of improvement efforts underway:
|
We apply the 5Rs of maternal care as an organizing principle to highlight opportunities for diagnostic safety improvements in the hemorrhage case above (Melissa’s Story). However, the same concept can be applied to any SMM or MM outcome.
Call to Action
Maternal morbidity and mortality are major public health concerns. Understanding how diagnostic safety contributes to maternal morbidity and mortality can play a significant role in developing interventions to decrease SMM and MM rates in the US and abroad. There are a number of different approaches to address delays in recognition and escalation of obstetric emergencies. More research is needed to expand this area and address key concerns.
Ariel de Roche, MS (@Ariel_deRoche), is a maternal health advocate and birth and postpartum doula in NYC. Lili S. Wei, MD (@DrLiliWei), is a Maternal Fetal Medicine Physician at NYU Langone Health Brooklyn. Dena Goffman, MD, FACOG (@DenaGoffmanMD), is Vice Chair of Quality and Patient Safety for the Department of Obstetrics and Gynecology at Columbia University Irving Medical Center, the Chief of Obstetrics at Sloane Hospital for Women and the Associate Chief Quality Officer for Obstetrics at NewYork Presbyterian. Komal Bajaj, MD, MS-HPEd (@KomalBajajMD), is Chief Quality Officer at NYC Health + Hospitals/Jacob and Clinical Co-Director of NYC Health + Hospitals Simulation Center.
*Story and name used with Melissa Price’s permission. It originally appeared as part of the CMQCC Obstetric Hemorrhage Toolkit.
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