In this section :
- Hospital harm is everyone’s concern
-
Hospital Harm Improvement Resource
- How to Use the Hospital Harm Measure for Improvement
- Learning from Harm
- General Patient Safety Quality Improvement and Measurement Resources
- Hypoglycemia: Introduction
- Aspiration Pneumonia: Introduction
- Delirium: Introduction
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Infusion, Transfusion and Injection Complications: Introduction
- Infusion, Transfusion and Injection Complications: Discharge Abstract Database
- Infusion, Transfusion and Injection Complications: Importance to Patients and Families
- Infusion, Transfusion and Injection Complications: Clinical and System Reviews, Incident Analyses
- Infusion, Transfusion and Injection Complications: Measures
- Infusion, Transfusion and Injection Complications: Success Stories
- Infusion, Transfusion and Injection Complications: References
- Medication Incidents: Introduction
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Obstetric Hemorrhage: Introduction
- Obstetric Hemorrhage: Discharge Abstract Database
- Obstetric Hemorrhage: Importance to Patients and Families
- Obstetric Hemorrhage: Clinical and System Reviews, Incident Analyses
- Obstetric Hemorrhage: Measures
- Obstetric Hemorrhage: Success Stories
- Obstetric Hemorrhage: References
- Patient Trauma: Introduction
- Pneumonia: Introduction
- Pneumothorax: Introduction
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Post Procedural Infections: Introduction
- Post Procedural Infections: Discharge Abstract Database
- Post Procedural Infections: Importance to Patients and Families
- Post Procedural Infections: Clinical and Systems Reviews, Incident Analyses
- Post Procedural Infections: Measures
- Post Procedural Infections: Success Stories
- Post Procedural Infections: References
- Pressure Ulcer: Introduction
- Sepsis: Introduction
- UTI: Introduction
- Venous Thromboembolism: Introduction
- Wound Disruption: Introduction
- Obstetric Trauma: Introduction
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Procedure-Associated Shock: Introduction
- Procedure-Associated Shock: Discharge Abstract Database
- Procedure-Associated Shock: Importance to Patients and Families
- Procedure-Associated Shock: Clinical and System Review, Incident Analysis
- Procedure-Associated Shock: Measures
- Procedure-Associated Shock: Success Stories
- Procedure-Associated Shock: References
- Selected Serious Events: Introduction
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Electrolyte and Fluid Imbalance: Introduction
- Electrolyte and Fluid Imbalance: Discharge Abstract Database
- Electrolyte and Fluid Imbalance: Importance to Patients and Families
- Electrolyte and Fluid Imbalance: Clinical and System Reviews, Incident Analyses
- Electrolyte and Fluid Imbalance: Measures
- Electrolyte and Fluid Imbalance: Success Stories
- Electrolyte and Fluid Imbalance: References
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Anemia – Hemorrhage (Health Care / Medication Associated Condition): Introduction
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): Discharge Abstract Database
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): Importance to Patients and Families
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): Clinical and System Reviews, Incident Analyses
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): Measures
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): Success Stories
- Anemia – Hemorrhage (Health Care / Medication Associated Condition): References
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Anemia – Hemorrhage (Procedure-Associated Conditions): Introduction
- Anemia – Hemorrhage (Procedure-Associated Conditions): Discharge Abstract Database
- Anemia – Hemorrhage (Procedure-Associated Conditions): Importance to Patients and Families
- Anemia – Hemorrhage (Procedure-Associated Conditions): Clinical and System Reviews, Incident Analyses
- Anemia – Hemorrhage (Procedure-Associated Conditions): Measures
- Anemia – Hemorrhage (Procedure-Associated Conditions): Success Stories
- Anemia – Hemorrhage (Procedure-Associated Conditions): References
- Birth Trauma: Introduction
- Device Failure: Introduction
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Infections due to Clostridium difficile, MRSA or VRE: Introduction
- Infections due to Clostridium difficile, MRSA or VRE: Discharge Abstract Database
- Infections due to Clostridium difficile, MRSA or VRE: Importance to Patients and Families
- Infections due to Clostridium difficile, MRSA or VRE: Surveillance, Outbreak Management
- Infections due to Clostridium difficile, MRSA or VRE: Clinical and System Reviews, Incident Analyses
- Infections due to Clostridium difficile, MRSA or VRE: Measures
- Infections due to Clostridium difficile, MRSA or VRE: Success Stories
- Infections due to Clostridium difficile, MRSA or VRE: References
- Laceration: Introduction
- Retained Foreign Body: Introduction
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Viral Gastroenteritis: Introduction
- Viral Gastroenteritis: Discharge Abstract Database
- Viral Gastroenteritis: Importance to Patients and Families
- Viral Gastroenteritis: Surveillance, Outbreak Management
- Viral Gastroenteritis: Clinical and System Reviews, Incident Analyses
- Viral Gastroenteritis: Measures
- Viral Gastroenteritis: Success Stories
- Viral Gastroenteritis: References
Obstetric Hemorrhage: Clinical and System Reviews, Incident Analyses
Given the broad range of potential causes of obstetrical hemorrhage, clinical and system reviews should be conducted to identify potential causes and determine appropriate recommendations.
Occurrences of harm are often complex with many contributing factors. Organizations need to:
- Measure and monitor the types and frequency of these occurrences.
- Use appropriate analytical methods to understand the contributing factors.
- Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
- Have mechanisms in place to mitigate consequences of harm when it occurs.
To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for conducting chart audits and analysis methods are included in the Hospital Harm Improvement Resources Introduction
If your review reveals that your cases of obstetric Hemorrhage are linked to specific processes or procedures, you may find these resources helpful:
- Association of Ontario Midwives. https://www.ontariomidwives.ca/
- Postpartum Hemorrhage. 2016. https://www.ontariomidwives.ca/sites/default/files/CPG%20full%20guidelines/CPG-Postpartum-hemorrhage-PUB.pdf
- American College of Obstetricians and Gynecologists (ACOG). https://www.acog.org/
- Obstetrics & Gynecology. ACOG Practice Bulletin: Postpartum Hemorrhage. 2017. DOI: https://journals.lww.com/greenjournal/Abstract/2017/10000/Practice_Bulletin_No__183__Postpartum_Hemorrhage.56.aspx
- Obstetric Hemorrhage Bundle, Guidance Documents, and Additional Resources https://www.acog.org/About-ACOG/ACOG-Districts/District-II/SMI-OB-Hemorrhage?IsMobileSet=false
- Committee Opinion: Preparing for Clinical Emergencies in Obstetrics and Gynecology. 2014. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Patient-Safety-and-Quality-Improvement/co590.pdf?dmc=1&ts=20200212T1519391856
- Committee Opinion: Quantitative Blood Loss in Obstetric Hemorrhage. 2019. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co794.pdf?dmc=1&ts=20200212T1515359038
- Association of Women's Health Obstetric Neonatal Nurses (AWHONN). https://awhonn.org/
- Postpartum Hemorrhage. http://pphproject.org/
- California Maternal Quality Care Collaborative. https://www.cmqcc.org/
- OB Hemorrhage Toolkit V 2.0. 2015. https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit
- Institute for Healthcare Improvement (IHI). www.ihi.org
- How-to Guide: Prevent obstetrical adverse events. 2012. http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventObstetricalAdverseEvents.aspx
- National Institute for Health and Care Excellence (NICE) www.nice.org.uk
- Intrapartum care for healthy women and babies: Clinical guideline [CG190]. Published date: 2014 Last updated: 2017 https://www.nice.org.uk/guidance/cg190/chapter/Recommendations#third-stage-of-labour
- The Global Library of Women’s Medicine. https://www.glowm.com/
- A Comprehensive Textbook of Postpartum Hemorrhage 2nd Edition. https://www.glowm.com/resource_contents/resource_doc/675
- The Society of Obstetricians and Gynaecologists of Canada (SOGC) - https://www.sogc.org/en/
- Journal of Obstetrics and Gynaecology of Canada (JOGC). No. 235-Active Management of the Third Stage of Labour: Prevention and Treatment of Postpartum Hemorrhage. 2018. https://www.jogc.com/article/S1701-2163(18)30766-7/fulltext
- World Health Organization
- WHO recommendations for the prevention and treatment of postpartum haemorrhage. 2012. https://www.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf?ua=1
- Uterotonics for the prevention of postpartum haemorrhage. 2018. http://apps.who.int/iris/bitstream/handle/10665/277276/9789241550420-eng.pdf?ua=1&ua=1
- WHO Recommendations: Uterotonics for the prevention of postpartum haemorrhage Power Point Presentation. https://www.who.int/reproductivehealth/uterotonics-for-PPH-prevention-slidedoc.pptx?ua=1
Obstetric Hemorrhage
