Why We Can't Prevent 3 out of 5 Maternal Deaths
The CDC says three out of five pregnancy-related deaths in the U.S. are preventable. But we are not preventing them and 420 mothers die every year. (That's 70 more deaths than were caused by the two 737 Max accidents - and you saw the angst those deaths caused.) The U.S. has seen its maternal mortality rate rise for decades while most other countries have experienced declines. Here are 2 reasons why we're failing, and what to do about it.
2 Reasons We are Not Preventing the Preventable
1. We don't practice emergencies often enough or well enough. Obstetric emergencies, like severe bleeding and amniotic fluid embolism cause the most deaths at time of delivery. We are clearly not handling these emergencies as well as we should. What to do about it: These are "known failure modes" and each of the emergencies must be practiced in a team setting by every clinician - including the physician - at least every nine months. Scenarios must be realistic, challenging, and extensively debriefed.
2. We don't recognize, or respond to, the key warning signs after delivery. Severe bleeding, high blood pressure and infections are the most common causes of death in the week after delivery. A lack of knowledge among patients and providers about the warning signs and delays in treatment were among some of the leading contributing factors identified by the CDC report. Meaning that even when the signs are recognized, communications failures between the nurse and physician led to a treatment delay. What to do about it: Again, these warning signs are "known failure modes." Just like airline pilots are trained to recognize the warning signs of an impending adverse event, clinicians must be trained to expertly recognize these warning signs after delivery. Secondly, every team member must have assertion training and be able to speak up and "stop-the-line" when they perceive a problem with the reaction to one of these warning signs.
The Critical Lessons for Healthcare Teams
Just as we learned from the root causes of the 737 Max accidents, we must know the likely "failure modes" of the procedures and care we provide. Almost none of the maternal care provided has a triply redundant computer systems back up. Therefore, safety and reliability is predicated on the clinician being able to recognize the common "failure modes" and provide expert preventive care in a timely manner. What the CDC report tells us is that we must improve our recognition of "failure modes" and our performance when those failures happen. Improvement begins when we can answer three questions:
1. What is most likely to "fail"?
2. How would I recognize that?
3. What would I do about it?
Here's a quick test you can run: Go ask several of your clinicians this question, "What is one of the main causes of death during delivery?" Whatever answer they provide, ask, "How would you recognize that problem was beginning to happen?" If you are not satisfied with the answers you receive, remember that performance always sinks to the level of our training.
Want to get your healthcare team trained to prevent the preventable? If you need help designing, conducting, and debriefing realistic training scenarios, or need effective training to recognize warning signs of impending adverse events, or need to create a culture of accountability, LifeWings can help. Schedule a call today.