Joint Commission urges hospitals to take steps to prevent pregnancy-related deaths

Pre-existing medical conditions such as high blood pressure are putting women at greater risk for death during or shortly after pregnancy, according to a Joint Commission Sentinel Event Alert issued today.

The Alert comes as federal and state governments are stepping up efforts to identify the causes of maternal deaths in order to prevent them. The most current statistics from the Centers for Disease Control and Prevention (CDC) show that there are 13.3 maternal deaths per 100,000 live births, well over the target of 3.3 maternal deaths per 100,000 live births set as part of the U.S. government's Healthy People 2010 initiative. Common preventable causes that lead to maternal deaths include uncontrolled high blood pressure, undiagnosed fluid build-up in the lungs of women with pre-eclampsia, failure to pay attention to vital signs after a Cesarean section, and hemorrhage following a Cesarean section.

"It is a profound tragedy whenever a mother dies in childbirth. Fortunately, these are rare events," says Mark R. Chassin, M.D., M.P.P., M.P.H., president, The Joint Commission. "Achieving our national goal of reducing their frequency even further requires organizations and caregivers to have a thorough understanding of the underlying causes of maternal deaths and a disciplined focus on assuring consistent excellence in the early recognition and management of complications of delivery."

To prevent pregnancy-related deaths and severe illness, The Joint Commission's Sentinel Event Alert suggests that hospitals take a series of six specific steps, including the following:

-- Educate physicians and other caregivers about underlying conditions such as high blood pressure, diabetes or morbid obesity that may put women at risk if they become pregnant. -- Use specific protocols to treat pregnant women who have, for example, experienced a change in vital signs, hemorrhage or pre-eclampsia. -- Train emergency room staff to consider whether female patients may be pregnant or recently pregnant. Pregnancy can affect the diagnostic process or change a woman's response to treatment.

For women who are identified as being at high risk because of existing conditions such as high blood pressure, diabetes or morbid obesity, the Alert calls for referrals to experienced prenatal care providers who can provide specialized services. In order to avoid pulmonary embolism, The Joint Commission urges hospitals to make pneumatic compression devices available to high-risk patients undergoing a Cesarean section. Finally, hospitals are urged to evaluate whether pregnant women who are at high risk for dangerous blood clots (thromboembolism) should receive a special dosage of blood thinner after giving birth.

In addition to the specific recommendations contained in the Alert, the Joint Commission urges hospitals to use its accreditation standards to improve safety for pregnant women. The standards require hospitals to have a process for recognizing and responding as soon as a patient's condition appears to be worsening, and to develop written criteria for early warning signs that a patient's condition is deteriorating. The standards also address staff response to concerns about a patient's condition and educating patients and families about how to get help if they have concerns.

The warning about maternal deaths is part of a series of Alerts issued by the Joint Commission. Much of the information and guidance provided in these Alerts is drawn from The Joint Commission's Sentinel Event Database, one of the nation's most comprehensive voluntary reporting systems for serious adverse events in health care. Previous Alerts have addressed health care technology, anticoagulants, wrong-site surgery, medication mix-ups, health care-associated infections, and patient suicides, among others. The complete list and text of past issues of Sentinel Event Alert can be found at http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/.

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