Driver Diagrams Reduction of Obstetrical Harm - Hemorrhage OHA HEN 2.0.

Slides:



Advertisements
Similar presentations
TEAMWORK AND COMMUNICATION TRAINING
Advertisements

Wrap-up of Obstetrical Harm Prevention Project Anne Banfield, MD, FACOG.
OB Hemorrhage: A Collaborative Approach to Standardization Presented by: Kristi McClure, RN, MSN, C-EFM Clinical Educator, MCW June 26, 2014.
Maternal Affinity Group September 25, Objectives Name at least 3 of the core elements of Postpartum Hemorrhage Identify the need for a risk factor.
MSC Confidential Take the Shock Out of Sepsis. MSC Confidential Why Use Simulation?
Ashika Maharaj/Gill Robb Improvement Science Professional Development Program Tackling Opioid-related Harm.
“Risky States” Optimizing ICU Safety Through Patient Engagement, System Science and Information Technology Beth Israel Deaconess Medical Center; MIT;
RENI PRIMA GUSTY, SK.p,M.Kes
Having the Conversation Practical Tips for Effective Advance Care Planning Revathi A-Davidson Jean Anderson March 28 th, 2015.
The Future of Stroke in Your State: Kansas Janice Sandt MS,BSN,RN,CCM FINANCIAL DISCLOSURES: None UNLABELED/UNAPPROVED USES DISCLOSURE: None.
Case Example Management for Quality Services Dr. ENKHTUR Shonkhuuz Director General of the N.Gendenjamts’s Memorial National Center for Maternal and Child.
How You Can Help A Walk Through the Family Toolkit A Resource for Families Supporting Children, Youth and Adults with a Mental or Substance Use Disorder.
Chapter 17 Nursing Diagnosis
Nurse Staffing in New Hampshire Implementing a Nurse Staffing Committee NH Staffing Toolkit July 2010.
M Purpose Improvement Tools/Methods Limitations / Lessons Learned Results Process Improvement Improving Hospital-Acquired Pressure Ulcers at Discharge.
20,000 Days Campaign Storyboard Learning Session 3, March 2013
Experience feed back committee (EFBC) in radiotherapy M. Delgaudine, N. Jansen, P. Coucke Department of Radiotherapy, CHU-Liège, Belgium
CLABSI Supplemental Call Series Best Practices: How Successful Units Engaged Their Senior Executive Leaders October 18, 2011 Presenters: Jonathan Kling,
MARYLAND PATIENT SAFETY CENTER PERINATAL COLLABORATIVE AND LEARNING NETWORK Secretary’s Advisory Committee on Infant Mortality March 9, 2012 Raymond L.
Maternal Newborn Safety Initiatives Dr. James Betoni, MFM Dr. Stewart Lawrence, Neonatologist Debbie Ketchum, BSN,RNC,MAOM Saint Alphonsus Regional Medical.
Obstacles of optimum care for diabetic children in Palestine Prepared by Dr.Intisar Al-Alem November 2008.
ANN HENDRICH, RN, PHD, F.A.A.N. SENIOR VICE PRESIDENT, CLINICAL QUALITY & SAFETY CNO & EXECUTIVE DIRECTOR, PATIENT SAFETY ORGANIZATION SEPTEMBER 10, 2012.
Department of Obstetrics and Gynecology PPH: We don’t need NO stinkin’ blood! June 11, 2015.
Copyright Medical Group Management Association. All rights reserved. Name, credentials Organization Date Preparing Your Office Practice for Disaster.
Gaston Sorgho Harvard School of Public Health
Incorporating Preconception Health into MCH Services
Excellence in Obstetrics A MULTI-SITE AHRQ DEMONSTRATION PROJECT Ann Hendrich, RN, PhD, F.A.A.N Vice President, Clinical Excellence Operations Executive.
Copyright 2002, Delmar, A division of Thomson Learning.
Fundamental Nursing Skills and Concepts Chapter 2.
Safety and Quality Collaborative CHAT Asthma Collaborative Maintenance of Certification (MOC)
Building Human Resource Management SkillsNational Food Service Management Institute 1 Crisis Management Procedure and Practice Objectives At the completion.
Standard 2. Diagnosis The registered nurse analyzes the assessment data to determine the diagnosis or the issues.
Northern California Mortality Reduction Getting Results to Scale Dr. Carmen Adams.
HAI Affinity Group CAUTI Prevention: The Nurse Driven Protocol for Catheter Removal April 10, 2013 Denise Flook, RN, MPH, CIC HAI Collaborative Lead Vice.
Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide Prevention of PPH requires early recognition and intervention,
National Patient Safety Goals 2008 T he University of Toledo Medical Center Toledo, Ohio.
Postpartum Hemorrhage: Creating an Evidence-Based Safety Bundle ERIN A. S. CLARK, MD MATERNAL-FETAL MEDICINE.
Affiliated with Children’s Medical Services Affiliated with Children’s Medical Services Introduction to the Medical Home Part 4 How Can Assessment Tools.
Canadian Best Practice Recommendations for Stroke Care Recommendation 1: Public Awareness and Patient Education (Updated 2008)
Falls Driver Diagram OHA HEN 2.0. Fall Prevention AIMPrimary Drivers Secondary DriversChange Ideas Reduce Patient Falls Fall and Injury Risk Assessment.
Readmissions Driver Diagram OHA HEN 2.0. Readmissions AIMPrimary Drivers Secondary DriversChange Ideas Reduce Readmissions Identify patients at high-risk.
Credit Valley Hospital Patient Flow Purpose of Initiative To improve the flow of admitted patients from the emergency room to the medical units and improve.
Obstetric Hemorrhage Measures Outcome Process Structural (“deliverables”) Data Quality California Partnership for Maternal Safety Patient Safety First.
Iatrogenic Delirium Driver Diagram AIMPrimary Drivers Secondary Drivers Change Ideas Reduction incidence of Iatrogenic Delirium Early Identification &
Elliott Main, MD Stanford University California Maternal Quality Care Collaborative.
THIS MAY BE USED FOR ANY INCISION.
TeamSTEPPS for Office-Based Care Implementation Planning.
Dr. Rashida Abdelfattah FACULTY OF NURSING SCIENCES University of Khartoum.
Driver Diagrams Reduction of Early Elective Deliveries OHA HEN 2.0.
ADVERSE DRUG EVENT (ADE) Driver Diagram OHA HEN 2.0.
Deborah Kilday, MSN, RN Senior Performance Partner Premier, Inc. Premier’s Focus: OB Harm Reduction September 11, 2015.
Hospital Acquired Pressure Ulcers Driver Diagram
OBSTETRIC EMERGENCY DRILLS Improve the quality of care for women having obstetric emergencies.
Purpose Improvement Tools/Methods Limitations / Lessons Learned Statistics Process Improvement Increasing awareness of Pregnancy Induced Hypertension (PIH)
Brittany Waggoner MSN,RN, AGCNS-BC Hendricks Regional Health
CS Collaborative Kickoff Meeting January, 2017
Design / Reduce Variation
Monday 10th October 2011 Transforming Maternity Services Mini-Collaborative Introductory WebEx Call Call Facilitator : Cath Roberts Insert name of presentation.
Evaluating Sepsis Guidelines and Patient Outcomes
Department of Obstetrics and Gynecology
Obstetrical Hemorrhage Management
Lack of standardization
TeamSTEPPS Team Strategies and Tools to Enhance Performance & Patient Safety Lori Eckenrode BSN, RNC-OB Stacy.
Driver Diagrams Reduction of Obstetrical Harm – Pre-Eclampsia
UNIVERSITY OF TEXAS MEDICAL BRANCH At GALVESTON
OB Hemorrhage Bundle Implementation
Practicing for Patients
Quantification of Blood Loss in practice
Social Contract between………………………… and …………………….……….………………
PREVENTING MATERNAL MORTALITY AND MORBIDITY FROM OBSTETRIC HEMORRHAGE
Presentation transcript:

Driver Diagrams Reduction of Obstetrical Harm - Hemorrhage OHA HEN 2.0

Reduction of Obstetrical Harm - Hemorrhage AIMPrimary Drivers Secondary Drivers Change Ideas Reduction of OB Harm by 40% in Hemorrhage Standardize readiness for obstetric emergencies Implement standardized care delivery systems. Have emergency supplies and medications readily available through the use of standardized hemorrhage carts or kits Keep a hemorrhage kit at the medication station Through collaboration by physicians, nurses, and blood bank staff, develop a protocol for responses to hemorrhage using an evidence-based example such as Maternal Hemorrhage Toolkit found on Use policies, protocol examples, practice bundles, educational materials, and data collection tools that have already been created and are available from organizations such as CMQCC and IHI Standardize recognition of obstetric emergencies Implement standardized early warning systems to identify high risk patients. Rather than estimating utilize equipment that can identify and quantify blood loss such as drapes with calibrated collection systems Implement a tool that uses evidence-based triggers for the diagnosis and treatment of hemorrhage and in obstetric patients. Use standardized language to describe the amount of blood loss and fetal heart tracings in communication among the treatment team and the blood bank.

Reduction of Obstetrical Harm - Hemorrhage AIMN=Primary Drivers Secondary Drivers Change Ideas Reduction of OB Harm by 40% in Hemorrhage Standardize responses to obstetric emergency Implement and test standardized protocols for obstetric emergencies Place copies of the hemorrhage protocols in prominent places in each patient room. Conduct drills regularly with physicians and nurses to simulate emergencies. Conduct a thorough debriefing after each actual and simulated event to identify areas for improvement and obtain suggestions for improving future exercises. Allow all team members to speak and offer suggestions. Patient and Family Engagement Family Involvement Foster a culture that allows for patient and family involvement in care. Include patient and family in plan of care Educate patient and family on signs and symptoms.