IAPS 2024 Transparency and Safety in Healthcare

​​​2024-IAPS-winners​​​​​​​​

​OB/Newborn Patient Safety and Quality Committee
UPMC Hamot

A young couple came to UPMC Hamot to deliver their first child—what is supposed to be one of the most exciting moments of their lives. The labor was long and complicated, requiring a vacuum delivery due to recurrent significant variable decelerations, but he arrived, and his parents held and snuggled their perfect baby boy. Although he met the criteria for a healthy newborn, several post-delivery medical errors resulted in him going undiagnosed with a subgaleal hemorrhage which led to his death.

Transparency in healthcare is so important to patient safety and yet it is so challenging when things go dreadfully wrong. Despite how daunting the task was, the team had a duty to reflect on their errors, identify process improvement strategies for implementation, and share the story. That has been the guiding principle of their OB/Newborn Patient Safety and Quality committee.

A subgaleal hemorrhage is a rare but potentially lethal event in newborns: a life-threatening emergency caused by bleeding that accumulates between the skull and the scalp. The hemorrhage is typically caused by a rupture of the emissary veins (especially with vacuum-assisted births). It can lead to hypovolemic shock, anemia, coagulopathy, and death. Treatment includes bandage compression, aggressive administration of blood products, and surgery. This team learned from its extensive review of this case that opportunities existed in education, assessment skills, and the need for the development of a tool that would enable the staff to identify potential brain bleeds in these cases more quickly. 

For future patient safety in the hospital’s most vulnerable population, this committee developed necessary education and a tool that is now mandatory for all staff in the maternity departments. All newborns delivered with an instrumental assist are to have surveillance observations and examination at 1, 2, 3, 4, 6, 8, and 12 hours of age. In addition to baseline newborn observations (activity, color, heart rate, respiratory rate, and temperature), examination of the head includes visual inspection of the scalp and palpating the head to note any ballotable mass or movement of fluid (gravity dependent) in the scalp. Staff also notes the color and head shape, including displacement of the ears or pitting edema, and a head circumference. If there are any changes in the newborn from the immediate baseline, staff is to reach out for a bedside evaluation by the neonatal intensive care unit (NICU) or pediatric provider and a complete blood count is to be ordered. 

An open culture of transparency and patient safety allows for greater innovation to occur, as demonstrated by this committee in sharing the unfortunate, but impactful story with other newborn facilities for awareness and education to avoid another newborn tragedy in the future. 

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