Abstract

Postpartum hemorrhage resulting from uterine atony is one of the leading causes of maternal morbidity. If initial treatment for atony is unsuccessful, second-line uterotonics must be administered immediately.A retrospective observational study was performed to evaluate barriers to the management of postpartum hemorrhage on our unit. Fourteen multidisciplinary teams participated in postpartum hemorrhage simulation drills. Actions in the labor room and the medication room were video-recorded for analysis. Postsimulation video review revealed multiple system errors delaying the process of obtaining the secondary uterotonics: 1) computer-generated delay in entering the patient's identification; and 2) multiple locations for the three medications. A "postpartum hemorrhage kit" was developed by pharmacy services, which included methylergonovine, carboprost, and misoprostol. All three medications were then placed in the refrigerator in an insulated box. These changes 1) allowed all medications to be removed in a kit in one step; 2) the kit could be retrieved more easily as a result of adjustments made in the identification process; and 3) the foam insulation kept the carboprost cooled as required. The postpartum hemorrhage simulation scenario was repeated to evaluate delivery of uterotonic medications with access to the postpartum hemorrhage kit.After the corrections, time to retrieval of all three uterotonic medications decreased significantly from 2 minutes and 16 seconds before use of the kit to 29 seconds with the kit.Simulated scenarios exposed correctable delays in the retrieval of emergency medications. Simulation drills can be used to detect system errors, improve system processes, and potentially reduce maternal morbidity and mortality.

View details for DOI 10.1097/01.AOG.0000447124.24190.ec

View details for PubMedID 24770020