Perinatal & Neonatal Safety
In 2022, over 1,000 pregnancy-related deaths occurred across the U.S. and over 80% of those were preventable. Furthermore, each year 50,000-60,000 birthing people experience severe pregnancy-related events which must be reviewed for opportunities to improve. Maternal health and disparities in perinatal outcomes are a high priority in Maryland, and also nationwide.
Join MPSC throughout the year for virtual webinars, patient safety tools courses, confidential and protected roundtable discussions for shared and experiential learning, and safety reviews tailored for high priority adverse events in the maternal and child health space and on Labor and Delivery units.
Perinatal Safety Series
This series of easy-to-consume virtual webinars will highlight emerging patient safety trends and issues of critical need in the Emergency Department. The webinars will identify innovative strategies and implementation techniques to support ED teams in meeting their quality and safety goals and harm reduction.
Safety Series webinars are held from 12:00 – 1:00 pm EST and are FREE for MPSC Members. Registration fee for Non-members is $45.
Safe Tables
Safe Tables are a shared learning forum for peers to exchange patient safety experiences, discuss best practices, network and learn from each other in an open, uninhibited and legally protected environment.
Safe Tables are open and FREE to MPSC members only and are held in-person from 1:00 – 3:00pm EST.
Patient Safety Tools
Many healthcare professionals, particularly quality and safety leaders, use a variety of patient safety tools and techniques daily to ensure the delivery of highly-reliable care; but these tools also offer implementable, effective, and practical applications for front-line healthcare workers to improve patient safety systems and processes.
Patient Safety Tools courses are held virtually from 12:00 – 2:00 pm EST and are FREE to MPSC Members. Registration fee for Non-members is $79.
Perinatal Safety Fellowship
The Maryland Patient Safety Center is offering a year long Perinatal Quality and Safety fellowship. The Fellowship will begin in September, 2024 and help participating individuals design, implement, evaluate, and disseminate a perinatal quality improvement project aimed at improving outcomes and reducing disparities at their organization.
Learn More and Apply
Click here for information on our partnership with Count the Kicks, an evidence-based stillbirth prevention program to educate expectant parents in Maryland on the importance of tracking a baby’s movements daily during the third trimester of pregnancy.
MPSC in the News
WJZ Baltimore News I June 27, 2023
WEAA FM Radio Interview with Gabe Ortiz I June 22, 2023
Organizations should be using data to drive improvement. Unfortunately, data on perinatal processes and outcome measures can be hard to come by. During this one-hour webinar, we will discuss how to create a basic dashboard and leverage data from core perinatal measures to begin to build a solid foundation for a perinatal quality structure– driving improvement, increasing provider and staff engagement, and improving safety. Two organizations will share their dashboards and how they have used perinatal data.
The Obstetrics and Women’s Department at LifeBridge Sinai Hospital observed increased surgical site infections (SSIs) after cesarean delivery in 2021-2022. The problem was identified through staff reporting patient readmissions and quality reviews. An interdisciplinary team established a quality goal to decrease the incidence of SSI. An SSI prevention bundle was developed and implemented incrementally, which resulted in a decrease in SSIs. During this one-hour webinar, project leaders, and Minogue Award for Patient Safety Innovation Circle of Honor winners, will describe the background and significance of surgical site infections after cesarean delivery; how an evidence-based prevention bundle can impact outcomes; and the strategies to sustain practice change.
Approximately 10% of infants will require some help at birth, with 1% needing more extensive resuscitation. The Neonatal Resuscitation Program (NRP) emphasizes the importance of teamwork and communication and recognizes the impact of this on the effectiveness of resuscitation and patient outcomes. In a protected safe table environment participants will discuss factors that impact teamwork and communication in this space such as the physical environment, team composition and training, leadership, hierarchy, and communication.
This one-hour webinar will detail how Minogue Award for Patient Safety Innovation Circle of Honor winners, Greater Baltimore Medical Center, used principles of the Lean Management System to redesign care for patients experiencing postpartum hemorrhage, leading to improved outcomes and decreased severe maternal morbidity.
Over 50% of maternal deaths occur in the postpartum period. Necessitating awareness of -and collaboration on- obstetrical emergencies by non-obstetric health care providers. This presentation will explore ways to cultivate a culture of safety for maternal patients presenting to the emergency department and other outpatient areas. This one-hour webinar from Minogue Award for Patient Safety Innovation Circle of Honor winners, LifeBridge Health Carroll Hospital Center, will outline the implementation of a standard workflow and how improved utilization of existing resources can improve perinatal outcomes and patient satisfaction.
Severe maternal morbidity is associated with a high rate of preventability and should be considered a near miss. This two-hour webinar is designed to develop the participant’s understanding of how to review and analyze their organization’s perinatal adverse event data. Attendees will discuss how to create a process to identify maternal and neonatal cases in need of review, outline key stakeholders that should be included in the review, and describe strategies to review cases to determine opportunities for improvement.
This one-hour webinar aims to increase readiness to treat and support the Amniotic Fluid Embolism (AFE) patient, their families, and one another during and after an AFE event. It also provides a closer look at the current research and how healthcare teams can support the clinical research needed to prevent, predict, and treat AFE.
Failure mode and effects analysis (FMEA) is a prospective, team-based, structured process used to identify system failures of high-risk processes before they occur. Perinatal teams should examine high risk processes for their inherent risks using FMEA. This two-hour webinar will provide attendees with the tools to apply FMEA principles to perinatal workflows and processes to identify risk as well as possible failure modes, and their effects.
Uterine rupture is a rare and but potentially life-threatening event for both mother and fetus. Although many providers are familiar with the risk of uterine rupture among patients undergoing a trial of labor after cesarean, other risks are often underappreciated which could lead to a lack of recognition and delays in care. This presentation will describe current data on uterine rupture and outline preventative strategies, risk factors, signs, and symptoms.
Stillbirth is a public health crisis and each year approximately 21,000 babies are born still. Birthing people who experience stillbirth are at increased risk of severe maternal morbidity as well as other physical and emotional complications. Learn from Liz O’Donnel who, after the death of her daughter Aaliyah Denise, who was born still, at 31 weeks gestation. Liz strove to carry on her daughter’s name and legacy and started a nonprofit- Aaliyah in Action. Aaliyah in Action aims to support other families through loss by providing self-care resources. During this one-hour webinar, Liz will share her story and best practices to support families after stillbirth. Learn about available resources to support those who experienced stillbirth and how health care providers can best advocate for and support families experiencing loss.
Medical errors are a leading cause of patient morbidity and mortality. A variety of high-alert medications are used in labor and delivery including insulin, oxytocin, and Magnesium Sulfate. Additionally, other medications such as TXA and misoprostol although not high alert also confer significant risk if not administered properly. These medications coupled with the fast-paced environment which is labor and delivery result in a heightened risk of causing significant harm to mom and/or baby. This one-hour webinar will present cases of common medication errors in labor and delivery and risk mitigation strategies.
The Institute for Safe Medication Practices (ISMP) first wrote about medication errors involving oxytocin in 1999. Now 25 years later risks associated with oxytocin use continue. In a protected safe table environment participants will discuss nationwide trends in oxytocin-related adverse medication events and ISMP safe practice recommendations aimed at safeguarding against errors with oxytocin. Oxytocin checklists and how to standardize policies on oxytocin administration will be reviewed.