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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_antepart-hemorrhage.docx
May 01, 2017 - Sample Scenario for Antepartum Hemorrhage In Situ Simulation
Purpose of the tool: The Antepartum Hemorrhage … The facilitator should allow the patient to have pain and bleeding despite any and all diagnostic or … The facilitator should allow patient to continue bleeding despite any and all diagnostic or therapeutic … Trigger 1: Vaginal Bleeding First Noted
Targeted Behavioral Response
Observed
Not Observed
Notes … Nurse assesses vital signs, uterine status, fetal status, and checks for bleeding.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4t_combo_pdi08-postophemorrhage-bestpractices.pdf
May 16, 2016 - Risk Factor Determination Determine which factors place pediatric patient at an increased
risk of bleeding … procedure or
surgery is appropriate.5 Avoid medications that could increase
the risk of postoperative bleeding … patients and can be used to trigger notification of the responsible
surgeon of possible postoperative bleeding … o Frank bleeding and bruising.
o Tachycardia. … The management of postoperative bleeding. Surg Clin N Am 2005;85(6):1191-
1213.
6.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/ldu-safety-slides.html
July 01, 2023 - Slide 20: Obstetric Hemorrhage
Obstetric Hemorrhage
Slide 21: Key Safety Elements: Standardize … standardized approach including obstetric hemorrhage kits and carts for responding to hemorrhage episodes … Postpartum hemorrhage. … Obstetric Hemorrhage. … OB Hemorrhage Toolkit V 2.0.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4f_combo_psi09-postophemorrhage-bestpractices.pdf
May 20, 2016 - or Hematoma
Why Focus on Postoperative Hemorrhage and Hematoma? … • Postoperative bleeding is a risk associated with all surgical procedures. … below) that will
be used to trigger notification of the responsible surgeon of possible postoperative
bleeding … o Frank bleeding and bruising.
o Tachycardia. … The management of postoperative bleeding. Surg Clin N Am 2005;85(6):1191-
1213.
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-3.html
September 01, 2021 - For example, the National Partnership for Maternal Safety Consensus Bundle on Obstetric Hemorrhage includes … , personnel, and processes associated with improved assessment, diagnosis, and response to maternal hemorrhage … of obstetric emergencies, including shoulder dystocia, 32 maternal cardiac arrest, 33 and maternal hemorrhage … For example, in the Maternal Hemorrhage Case above, simulation could explore the causes of systemic issues … or processes, 43 including safety bundle components such as standardized stage-based treatment for hemorrhage
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-issuebrief-maternal-morbidity.pdf
September 01, 2021 - healthcare team.a The nurses
called the physician 30 minutes later to report a heart rate of 105b and more bleeding … tissue from within the uterus, thus excluding retained placental tissue as the cause
of increased bleeding … Limited physical exam and no lab tests
drawn to clarify extent of bleeding.
Figure 1. … Obstetric hemorrhage: a global review. … A state-wide obstetric hemorrhage quality improvement
initiative.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-196-section-2.pdf
January 01, 2016 - 800.2
Closed with other and unspecified intracranial hemorrhage 800.3
Closed with intracranial injury … 800.7
Open with other and unspecified intracranial hemorrhage 800.8
Open with intracranial injury … post injury 852.x
Other/unspecified intracranial hemorrhage following injury 853.x
Intracranial … injury of other and unspecified nature 854.x
Subarachnoid hemorrhage 430
Intracerebral hemorrhage … 431
Other and unspecified intracranial hemorrhage 432.x
Child abuse and neglect 995.5x
Observation
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety.pptx
May 01, 2017 - are available through the SPPC:
Antepartum hemorrhage
Postpartum hemorrhage
These scenarios reinforce … Obstetric Hemorrhage. … Measuring and communicating blood loss during obstetric hemorrhage. … OB Hemorrhage Toolkit V 2.0. … Postpartum Hemorrhage: Resources. 2014 http://www.perinatalweb.org/major-initiatives/postpartum-hemorrhage
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-2.html
September 01, 2021 - , recognition of hemorrhage could be improved through awareness of risk factors, accurate assessment … Case Discussion: Maternal Hemorrhage 20
Composite Case Example: A healthy 24-year-old presented at … team. a The nurses called the physician 30 minutes later to report a heart rate of 105 b and more bleeding … minimal tissue from within the uterus, thus excluding retained placental tissue as the cause of increased bleeding … Limited physical exam and no lab tests drawn to clarify extent of bleeding.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety-fac-guide.html
July 01, 2023 - Obstetric hemorrhage.
Umbilical cord prolapse. … from the tool related to obstetric hemorrhage. … to management and timely treatment intensification for responding to identified obstetric hemorrhages … The use of standardized obstetric hemorrhage kits and carts. … These scenarios, one for antepartum hemorrhage and one for postpartum hemorrhage, reinforce teamwork
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.docx
May 01, 2017 - Slide 20
SAY:
The first consideration of L&D unit safety for management of obstetric hemorrhage … The key safety elements focus on a hemorrhage response protocol that provides a standardized approach … to management and timely treatment intensification for responding to identified obstetric hemorrhages … The use of standardized obstetric hemorrhage kits and carts. … These scenarios, one for antepartum hemorrhage and one for postpartum hemorrhage, reinforce teamwork
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-6.html
September 01, 2021 - Obstetric hemorrhage: a global review. … A state-wide obstetric hemorrhage quality improvement initiative. … National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage. … Reduction of severe maternal morbidity from hemorrhage using a state perinatal quality collaborative. … Impact of simulation and team training on postpartum hemorrhage management in non-academic centers.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.pdf
May 01, 2017 - to management and
timely treatment intensification for responding
to identified obstetric hemorrhages … .18-21
o Individual risk factors predict some
occurrences of obstetric
hemorrhage. … o Risk assessments may include the
presence of clinical conditions that
increase risk of hemorrhage … • The use of standardized obstetric
hemorrhage kits and carts. … These
scenarios, one for antepartum hemorrhage
and one for postpartum hemorrhage, reinforce
teamwork
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_1-introduction.pptx
July 01, 2023 - Introduction to the SPPC-II Teamwork Toolkit for Obstetric Hemorrhage - PowerPoint Presentation
Introduction … Toolkit Purpose
Connects to AIM Patient Safety Bundle concepts via the 4 Rs
Also available for Obstetric Hemorrhage … A similar toolkit is available for AIM’s Obstetric Hemorrhage Patient Safety Bundle.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_8_program-evaluation.pptx
July 01, 2023 - aims to integrate teamwork and provider communication aspects with the AIM patient safety bundles for hemorrhage … Over time, the contribution of traditional causes of maternal mortality represented by hemorrhage, hypertensive … However, it has been shown that preventable deaths are those contributed by conditions like hemorrhage … medical condition 28.7 17.600000000000001 13.1 11.9 7.6 2.5 3 5.6 3.6 8.7000000000000011 1991-1997 Hemorrhage … The SMM metric, overall and bundle-specific, for example SMM among women with hemorrhage or SMM women
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/vtguide/appc.html
May 01, 2016 - Bleeding Risk Factors and Contraindications to Anticoagulant Prophylaxis
Active bleeding. … Concern over CNS bleeding (brain or spinal cord surgery in last week, recent intracranial hemorrhage, … hemorrhage
431
Intracerebral Hemorrhage
432.X
Other and unspecified intracranial hemorrhage … 459.0
Hemorrhage, unspecified
530.82
Esophageal hemorrhage
568.81
Hemoperitoneum (nontraumatic … )
569.3
Hemorrhage of rectum and anus
578.0
Hematemesis
578.1
Blood in stool
578.9
Hemorrhage
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_8_program-evaluation.pptx
July 01, 2023 - and strategies with the Alliance for Innovation on Maternal Health (AIM) patient safety bundles for hemorrhage … aims to integrate teamwork and provider communication aspects with the AIM patient safety bundles for hemorrhage … However, it has been shown that preventable deaths are those contributed by conditions like hemorrhage … medical condition 28.7 17.600000000000001 13.1 11.9 7.6 2.5 3 5.6 3.6 8.7000000000000011 1991-1997 Hemorrhage … The SMM metric, overall and bundle-specific, for example SMM among women with hemorrhage or SMM women
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ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/baker.html
August 01, 2017 - The final, selected events were: Shoulder Dystocia, Post-Partum Hemorrhage, Intra‑Partum Fetal Death … Pregnant
Experienced a Medical Mistake
Works in Health Care
Unplanned Return to OR or L&D for Bleeding … Experienced a Medical Mistake
Completed TeamSTEPPS Training
Unplanned Return to OR or L&D for Bleeding … Event type (e.g., Shoulder Dystocia, Post-Partum Hemorrhage) mattered least during the Delivery phase … Unplanned Return (N=3); Shoulder Dystocia (N=3); Post‑Partum Hemorrhage (N=4); Intra-Partum Fetal Death
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/frontline-cases-studies.pdf
May 01, 2015 - toolkit to
develop their approach to hemorrhage reduction. … Our goal is to decrease our incidence
of hemorrhage by 50 percent.” … really, with, what is the definition of hemorrhage? … only blood loss after delivery was quantified, which
resulted in an underestimation of the number of hemorrhages … Targeting Obstetric Hemorrhage Care
The team chose to target obstetric hemorrhage care practices because
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/situ/simulation-slides.html
July 01, 2023 - Antepartum hemorrhage.
Preeclampsia/seizure. … In: CMQCC Obstetric Hemorrhage Toolkit: Obstetric Hemorrhage Care Guidelines and Compendium of Best Practices … Postpartum Hemorrhage: Resources. … https://www.perinatalweb.org/major-initiatives/postpartum-hemorrhage/resources . … OB Hemorrhage Toolkit V 2.0.