Communication is Key to Preventing Deaths or Serious Injury of Infants During Childbirth
In the past 10 years, hospitals have voluntarily reported 47 cases of infant death or disability during childbirth to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for review under the Sentinel Event Policy. Forty of the cases resulted in infant death and seven cases involved permanent disability. The mothers ranged in age from 13 to 41.
According to the Joint Commission, in the cases studied, communication issues were identified as the most common root causes of the death (72 percent), with more than half of the hospitals (55 percent) citing organization culture as a barrier to effective communication and teamwork, i.e., hierarchy and intimidation, failure to function as a team, and failure to follow the chain-of-communication.
Other causes include:
- staff competency (47 percent),
- orientation and training process (40 percent),
- inadequate fetal monitoring (34 percent),
- unavailable monitoring equipment and/or drugs (30 percent),
- credentialing/privileging/supervision issues for physicians and nurse midwives (30 percent),
- staffing issues (25 percent),
- physician unavailable or delayed (19 percent), and
- unavailability of prenatal information (11 percent).
The risk reduction strategies identified by JCAHO included:
- Revise orientation and training process (70 percent)
- Physician education and counseling (36 percent)
- Revise communication protocols (36 percent)
- Reinforce chain-of-communication policy (28 percent)