Has the Safety Fairy Come to Your

Hospital?

Poster Presentation

No one wakes up, goes to work, and plans to

make a mistake, but humans do make mistakes.

Health care is complex, thus it can fail in a complex

way. The health care system is designed so that a sin-

gle human error will not cause harm to the patient.

There are three ways that humansperform: skill based,

rule based, andknowledgebased.Twenty-¢ve percent

of errors are skill based, 60% of errors are rule based,

and15 % of errors are a result of lack of knowledge.

To create and sustain a culture of safety, a toolkit for

sta¡ is needed. The patient safety toolkit includes

the following: support the team through peer

checking and peer coaching; speak up using Cru-

cial Conversations; pay attention to detail by using

self-checking and standardized testing and report-

ing; use a questioning attitude by validating and

verifying information; communicate clearly by us-

ing the 3-Way repeat back and read back, clarify

questions; and use Situation-Background-Assess-

ment-Recommendation (SBAR) communication.

Using Peer Review to Measure

Competence in Fetal Heart Monitoring

Practice

Poster Presentation

Background

Although electronic fetal monitoring (EFM) is the

most common obstetric procedure (American

College of Obstetricians and Gynecologists

[ACOG], 2005), failure to interpret fetal heart moni-

toring (FHM) tracings and provide appropriate

interventions plays a role in poor neonatal out-

comes. Clinician failure to recognize an abnormal

FHR pattern may be due to lack of knowledge,

lack of training, or lack of skills assessment by

the employer or credentialing body (Miller, 2005).

As part of a unit-based EFM competency,

documentation of recognition of late fetal heart

rate decelerations and targeted nursing inter-

ventions were measured using a peer review audit

process.

Method

Interrater reliability was established between audi-

tors. Each month 40 charts, 20 labor inductions,

and 20 Pitocin augmentations are audited by a

team of sta¡ nurses who are Association of Wo-

men’s Health, Obstetric, and Neonatal Nurses FHM

Instructors and the Obstetric (OB) Informatics

nurse. Audits target nurses’ documentation of rec-

ognition and appropriate interventions for late

decelerations. When the auditor disagrees with the

case’s recognition or intervention, the case is for-

warded to one of two Advance Practice Nurses

(APNs). The APNs perform a second review and

collaborate with unit management for any identi¢ed

learning needs. Educational in-services were held

on the new National Institute of Child Health and

Human Development terminology from September

to December of 2008. Updates were emailed to sta¡

with issues identi¢ed in the audits, for example,

uterine tachysystole management. Monthly results

are posted, and nurses that demonstrate excel-

lence are recognized.

Results

The measure was calculated as the percentage of

auditor agreement with the case’s EFM documenta-

tion. From the July 2008 baseline of 54% agree-

ment, a steady improvement was noted through

2008 and 2009. Another result has been a change

Betsy Davis, RN, MSN, IB-

CLC, Women’s and Infant’s

Services, Spectrum Health,

Grand Rapids, MI

Janet M. Nelson, BSN, RNC-

OB, C-EFM, Nursing Educa-

tion, Spectrum Health, Grand

Rapids, MI

ProfessionalIssues

Jocelyn Davis, MSN, DNP,

CNM, Staff Development,

Summa Health System,

Akron City Hospital

campus, Akron, OH

Tiffany Kenny, MSN, RN,

Women’s Health Division,

Summa Health System,

Akron City Campus, Akron,

OH

Jennifer L. Doyle, MSN,

WHNP, Women’s Health

Services, Summa Health

System, Wadsworth, OH

Donna Copeland, RN,

Women’s Health Division,

Summa Health System,

Akron City Campus, Akron,

OH

JOGNN 2010; Vol. 39, Supplement 1 S53

Davis, J., Kenny, T., Doyle, J. L., Copeland, D. and Wigle, N. I N N O V A T I V E P R O G R A M S

Proceedings of the 2010 AWHONN Annual Convention

in culture resulting in keener awareness of patient

safety and collegial discussions of FHM tracings.

Adoption of the new NICHD FHM categories

occurred quickly. The need for multidisciplinary

FHM education and further mentoring of newer

nurses was reinforced. Cases of concern are now

forwarded to a multidisciplinary team for physician

peer review.

Discussion

This measure of EFM competence was dependent

on nurses documenting their actions. In certain

cases where late decelerations were documented,

we believe that interventions had probably been

provided but not documented. In a few instances,

two or three reviewers disagreed on a di⁄cult

tracing, highlighting the challenges of FHM inter-

pretation. Auditors noted that it is much easier to

recognize subtle changes in the tracing in retro-

spect when the outcomes were known. The value

of a multidisciplinary clinical documentation sys-

tem integrated with electronic FHM was evident

throughout this project.

Conclusion

Validation of EFM competence must be incorpo-

rated into all Labor and Delivery units’ EFM

practice, and bedside providers should be closely

engaged in this process. Clinicians deserve ongo-

ing support and education to create a culture of

safety and excellence. Additional research is

needed to identify factors that may interfere with

recognition, intervention, and documentation of

nursing EFM practice.

REFERENCESAmerican College of Obstetrics and Gynecology. (2005). Intrapartum fe-

tal heart rate monitoring. Practice bulletin no. 70. Obstetrics and

Gynecology, 114(1),192-202.

Miller, L. A. (2005). System errors in intrapartum electronic fetal monitor-

ing. Journal of Midwifery and Women’s Health, 50(6), 507-516.

A Performance Improvement Process for

Tackling Tachysystole

Poster Presentation

Background

Inappropriate use of oxytocin is one of the top ¢ve

areas of obstetric harm. Cases almost always in-

volve severely brain-damaged children, occa-

sionally involve maternal death, and consistently

result in multi-million-dollar jury verdicts. Histori-

cally there have been many issues: How many

contractions are too many? What if baby looks

¢ne? When do we intervene? Which of many terms

for it do we use? The 2008 National Institute of Child

Health and Human Development (NICHD) Update

on fetal monitoring helped clarify these issues, but

putting the evidence into action and avoiding ten-

dencies to ‘‘push the pit’’ can be challenging.

Purpose

The purpose of this presentation is to describe our

Level III perinatal center’s experience in tackling

tachysystole by standardizing care, addressing

multidisciplinary safety issues, and monitoring

progress to sustain improvement.

Method

In the summer of 2008, as part of the Premier Peri-

natal Safety Initiative, we created a team of nurses,

doctors, and administrators who reviewed existing

oxytocin administration policy and the current liter-

ature, benchmarked policy against other hospitals,

and developed an evidence-based algorithm for

uterine tachysystole and its management related to

fetal response. The physician leader of the team

took the algorithm to the major physician practice

for support. The algorithm was also discussed and

approved by physician departmental chairs and the

operations committee.

Interrater reliability was established, and every

month since, sta¡ nurses blindly audit 20 labor in-

ductions and 20 Pitocin augmentations. The audit

involves reviewing the fetal monitor strip and deter-

mining if tachysystole was avoided and if not was

the algorithm followed. Nurses are identi¢ed for in-

dividualized follow-up or education. Cases of

concern are also forwarded to a multidisciplinary

team for physician peer review. Educational up-

dates have been done in response to learning

Nancy Wigle, RN, Women’s

Health Division, Summa

Health System, Akron City

Campus, Akron, OH

ProfessionalIssues

Jennifer L. Doyle, MSN,

WHNP, Women’s Health Ser-

vices, Summa Health System,

Wadsworth, OH

Theresa Strecker, RN,

Women’s Health Division,

Summa Health System, Akron

City Campus, Akron, OH

Rebecca Austin, RN,

Women’s Health Division,

Summa Health System, Akron

City Campus, Akron, OH

S54 JOGNN, 39, S48-S84; 2010. DOI: 10.1111/j.1552-6909.2010.01121.x http://jognn.awhonn.org

I N N O V A T I V E P R O G R A M S

Proceedings of the 2010 AWHONN Annual Convention