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APHA Scientific Session and Event Listing

Nancy Corbett, RN¹, Kenneth T. Fong², Julie Nunes, RN, MS, CPHRM¹, Paul Preston, MD³, and Michael Leonard, MD². (1) Northern California Regional Risk Management, Kaiser Permanente, 1950 Franklin Street, 14th Floor, Oakland, CA 94612, 510-271-5740, nancy.corbett@kp.org, (2) National Risk Management, Kaiser Permanente, 1 Kaiser Plaza, 18th Floor, Oaklannd, CA 94612, (3) The Permanente Medical Group (TPMG), Kaiser Permanente, 2425 Geary Blvd., San Francisco, CA 94115

Birth Injuries are rare but serious problems in obstetrical care. Problematic communication and team dynamics, lack of information during hand-offs and supervision issues have been identified as key recurring organizational system problems that have increased the likelihood of birth injuries. In an effort to improve the patient safety and quality of care, our interdisciplinary team adapted innovative approaches from high risk industries to the perinatal care setting. This session will present the development of an interdisciplinary and regional team effort to create a culture of safety in the perinatal care at Kaiser Permanente through the transfer of successful practices. It will also present the key approaches that lead to this culture of safety. The program, known as the Perinatal Patient Safety Project (PPSP), was first developed at Kaiser Permanente's Northern California region in 2002. The successful practices and approaches from the Northern California Region were recognized to be innovative and effective at reducing birth injuries and were subsequently transferred to all of the other Kaiser Permanente Regions. The key innovative practices that support the culture of safety at the Kaiser Permanente perinatal units comprise of four main areas: 1) High reliability perinatal unit assessment; 2) definition of fetal well being / electronic fetal heart monitoring (EFM) training; 3) Human factors / effective communication / pre-procedural briefings; and 4) rehearsing emergencies. This session will present the evolution of these four approaches as they were disseminated to other regions at Kaiser Permanente and the implications and challenges for healthcare organizations.

Learning Objectives: At the conclusion of this session, the participant (learner) will be able to

• Describe the human factors approaches developed in high risk industries that can be adopted by health care settings.
• Identify multiple patient safety strategies that contribute to successful perinatal outcomes.

Keywords: Perinatal Outcomes, Pregnancy Outcomes

Presenting author's disclosure statement:

Not Answered