National Perinatal Information Center
National Perinatal Information Center


ARCHIVED WEBINAR

 
New Severe Maternal Morbidity Sentinel Event Policy:
Q&A with the Joint Commission Office of Quality and Patient Safety

In collaboration with the leadership of the Joint Commission Office of Quality and Patient Safety, NPIC provided an exclusive opportunity for member hospitals to discuss their concerns about operationalizing The Joint Commission New Severe Maternal Morbidity Sentinel Event Policy.

The leadership highlighted the forthcoming revision to The Joint Commission 2015 Comprehensive Accreditation Manual for Hospitals, provided clarification regarding severe maternal morbidity within the Sentinel Event Policy, and responded to member hospital questions.

Forthcoming revision to The Joint Commission 2015 Comprehensive Accreditation Manual for Hospitals that aims to provide clarity to severe maternal morbidity within the Sentinel Event Policy.

A sentinel event is a patient safety event (not primarily related to the natural course of the patient's illness or underlying condition) that reaches a patient and results in any of the following: Death, Permanent harm, Severe temporary harm.

Facilities are strongly encouraged to review all cases of severe maternal morbidity for learning and improvement.


Severe Maternal Morbidity
  • Any intrapartum (related to the birth process) maternal death

  • Severe maternal morbidity when it (not primarily related to the natural course of the patient's illness or underlying condition) reaches a patient and results in any of the following: Death, Permanent harm, Severe temporary harm*

*Severe maternal morbidity is defined, by the American College of Obstetrics and Gynecology, the US Centers for Disease Control and Prevention, and the Society of Maternal and Fetal Medicine, as a patient safety event that occurs intrapartum through the immediate postpartum period (24 hrs), that requires the transfusion of 4 or more units of packed red blood cells and/or admission to the intensive care unit (ICU).

Admission to the ICU is defined as admission to a unit that provides 24-hour medical supervision and is able to provide mechanical ventilation or continuous vasoactive drug support.
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Joint Commission Office of Quality and Patient Safety Speakers

Ron Wyatt, MD, MHA, DMS (HON)
Medical Director
Healthcare Improvement


Lisa Buczkowski, RN, MS, CPPS
Associate Director
Office of Quality & Patient Safety


Erin DuPree, MD, FACOG
CMO and Vice President
The Ctr. for Transforming Healthcare


Anita Giuntoli, RN, BSN, MJ
Associate Director
Office of Quality & Patient Safety


Event Recording
Recorded: March 19, 2015
Duration: 60 minutes
  Listen Now   Slides


Discussion Highlights
  • What about events occurring after 24 hours, such as delayed postpartum hemorrhage requiring 4 units of Packed Red Blood Cells or admission to the Intensive Care Unit for decompensation related to an underlying condition such as pulmonary hypertension?

  • What type of review and analysis will satisfy The Joint Commission when the event is known to arise from the patient's natural course of condition but still ensues with either an Intensive Care Unit admission or 4 or more units of Packed Red Blood Cells? For example, does a placenta accreta with anticipated blood product replacement and planned admission to an Intensive Care Unit after cesarean hysterectomy require a comprehensive systematic analysis?

  • If admitted to an Intensive Care Unit for 12 hours or less than 24 hours (primarily for observation) does this still fall in the Severe Maternal Morbidity category?

  • Why is the antepartum period not included in the definition of severe maternal morbidity?
             » For additional questions, launch the recording above.

Related Resources

Joint Commission Clarification of SMM Sentinel Event Policy

Case examples to illustrate the new definition

Changes to the Joint Commission Sentinel Events Chapter - Focus on Severe Maternal Morbidity

Severe Maternal Morbidity Reporting Forms
 
   
 
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