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PATIENT SAFETY SERIESDoes a postpartum hemorrhage patientsafety program result in sustainedchanges

in management and outcomes?

Brett D. Einerson, MD, MPH; Emily S. Miller, MD, MPH; William A.Grobman, MD, MBA

Pembimbing :Dr. Doddy Gutom,Sp.G

S!anna"##.$%#&.#'(

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ASTRA!T

B)E*+-E :+o determine !et!er t!e introdu/tion o0 a

postpartum !emorr!age 1PPH2 sa0ety programas asso/iated it! /!anges in /lini/al pra/ti/e

and out/omes,+o e3amine !et!er t!ese /!anges ere

sustained o4er time.

SE++5G : 5ort!estern

DESG5 : *o!ort Study

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ASTRA!T

6ES78+ : A0ter t!e introdu/tion o0 t!e program t!ere as

a signi9/ant in/rease in t!e use o0 uterotoni/medi/ations 1P.%%#2, intrauterine balloon

tamponade 1P.%%$2, B

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PR"#E$

Data 0rom a nationide sample in t!e 7S suggestt!at t!e rate o0 maternal !emorr!age !as risen0rom #.>? in #@@( to $.(? in $%%'.

+!e rate o0 se4ere PPH 1ie, estimated blood loss

EB8 C#=%% m82, !as doubled 0rom #@@@ t!roug!$%%'.

As a result, +!e )oint *ommission released a $%#%Sentinel E4ent Alert t!at urged !ospitals andobstetri/ pro4iders to de4elop and use proto/olsin an eort to pre4ent maternal morbidity andmortality related to PPH.

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%YP"T%ESIS+!e introdu/tion o0 a PPH patient sa0ety

program ould result to pre4ent more

se4ere PPH and redu/tion in maternalmorbidity

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!ASE ST&DY+!is as a /o!ort study o0 t!e /are and

out/omes be0ore and a0ter t!e

introdu/tion o0 a PPH patient sa0etyprogram at 5ort!estern MemorialHospital

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$ATERIA#S AND $ET%"D '()

mplementation o0 a multidis/iplinaryprogram t!at in/luded:

Mandatory edu/ational sessionsdesigned to impro4e EB8 assessmentit! preinter4ention andpostinter4ention testing

ntrodu/tion o0 a multidis/iplinary/!e/list 0or PPH management

+!e institution o0 uni4ersal a/ti4emanagement o0 t!e t!ird stage o0 labor

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$ATERIA#S AND $ET%"DS '*)

+!e a/ti4e management o0 t!e t!irdstage o0 labor

Administration o0 o3yto/in 1eit!erintramus/ular or intra4enous2immediately 0olloing deli4ery o0 t!e0etus

Gentle /ontrolled /ord tra/tion todeli4er t!e pla/enta.

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$ATERIA#S AND $ET%"DS '+)

Patients ere in/luded in t!e analysis i0:

+!ey !ad an EB8 o0 C=%% ml 0or4aginal deli4ery, C#%%% ml 0or/esarean deli4ery

+!ey re/ei4ed a blood trans0usion oruterotoni/ medi/ations 0or obstetri/

!emorr!age

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$ATERIA#S AND $ET%"D ',)

PA+E5+ *HA6A*+E6S+*S

Maternal demograp!i/: age, sel0