The Joint Commission issues Quick Safety advisory on preventing maternal death from obstetric hemorrhage


 Approximately 700 women in the United States die from pregnancy-related complications annually. The most frequent cause of severe and preventable maternal morbidity is obstetric hemorrhage or excessive blood loss from giving birth.

As the rates of maternal hemorrhage are increasing in developed countries, including the United States, The Joint Commission has issued a new Quick Safety advisory titled “Proactive prevention of maternal death from maternal hemorrhage.” The advisory reviews two new standards from The Joint Commission, effective July 1, 2020, that address complications in maternal hemorrhage and severe hypertension/preeclampsia.

The advisory also includes suggested strategies and safety actions to reduce morbidity and mortality from postpartum hemorrhage, including implementation of standardized and comprehensive obstetric safety bundles which provide structured procedures to improve care and outcomes using a set of evidence-based practices.

“Implementing evidence-based safety bundles has been shown to demonstrate significant reductions in maternal morbidity,” says Ana Pujols McKee, MD, executive vice president and chief medical officer, The Joint Commission. “The Joint Commission encourages health care organizations to implement these safety measures, and in doing so, help reduce the national maternal infant mortality and morbidity rate. Women and children across our nation deserve the attention of health care leaders to this matter.”

The consensus bundle on obstetric hemorrhage, developed by the Council on Patient Safety in Women’s Health Care, is organized into four action domains: Readiness, Recognition, Response, and Reporting/Systems Learning. 

Action items within these domains include:

  • Having a standardized, secured and dedicated hemorrhage supply kit that is stocked per a hospital’s defined process.
  • Assessing hemorrhage risk – prenatal, on admission, or other appropriate times.
  • Establishing a standardized, obstetric hemorrhage emergency management plan.
  • Establishing a culture of huddles for high-risk patients and post-event debriefs to identify success and opportunities for improvement.

For a complete list of action items and to access the full Quick Safety advisory, visit The Joint Commission website. The advisory may be reproduced if credited to The Joint Commission.

 



November 14, 2019


Topic Area: Press Release


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