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Severe Maternal Morbidity: Clarification of the New Joint Commission Sentinel Event Policy

January 28, 2015

In January 2015, the Joint Commission issued a revised definition for a sentinel event, expanding the concept for all specialties to include “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, or severe temporary harm” (1).  For obstetrics, the new definition for severe temporary harm focused on severe maternal morbidity defined as receiving 4 or more units of blood products (subsequently revised to 4 or more units of RBCs)  and/or ICU admission (2,3).  Although this revision brought more clarity and consistency to a general understanding of which cases meet criteria for sentinel events, it unintentionally created confusion about inclusion of all severe maternal morbidities.  A number of cases that meet the criteria for severe maternal morbidity will be primarily related to the natural course of the patient’s illness (such as bleeding from a placenta previa) and thus would not reach the level of a sentinel event.  Further, some cases meeting the criteria for severe maternal morbidity, which are not primarily related to the natural course of the woman’s illness, may, upon review, also not meet criteria for sentinel event. 

The purpose of reviewing adverse outcomes is not to be punitive; it is to learn and ultimately improve outcomes.  A culture of learning from adverse events, rather than a culture of blame and punishment, is critical to improving patient outcomes.  We strongly encourage that all cases of severe maternal morbidity, whether sentinel events or not, undergo a thorough and credible multidisciplinary comprehensive review (4,5) and analysis, resulting in an action plan for improvement, when appropriate.  There will certainly be opportunities to learn and improve from multidisciplinary review of these cases, even if they do not meet the criteria for a Joint Commission sentinel event.  Sentinel event review process should be reserved for those cases of severe maternal morbidity that are deemed to meet the Joint Commission definition.

The following case examples are offered to illustrate the new definition:


Example #1:

A  G4P3 woman with known placenta accreta underwent cesarean birth during which expected, but profound, bleeding occurs, requiring 4 units of packed red blood cells. She was monitored in the ICU overnight with a subsequent unremarkable postpartum stay and was discharged. 

Comment: Since this woman received four units of packed red blood cells and required ICU admission, this case meets the criteria for severe maternal morbidity and should undergo a multidisciplinary review. Although there may be identification of areas for improvement (these might include interventional radiology or consult with gynecologic oncology for additional surgical experience), this does not meet the criteria for a Joint Commission sentinel event because the patient’s underlying condition (placenta accreta) would be expected to result in this type of blood loss. Nevertheless, there may be areas for improvement to be identified. 

 

Example #2:

A woman at 40 weeks 0 days presented with preeclampsia with severe features and developed very elevated blood pressures requiring multiple medications and an ICU admission.  

Comment: This case is similar to case #1 and does not meet the criteria for a Joint Commission sentinel event because the patient’s underlying condition (preeclampsia with severe features) would be expected to result in this type of treatment. Again, this case would benefit from a multidisciplinary review for improvement opportunities. However, had she experienced a stroke, the case should be reviewed as a Joint Commission sentinel event given the severe temporary and potentially permanent harm related to the complication.

 

Example #3:

A G1P0 woman with gestational diabetes and preeclampsia was admitted for a medically indicated induction of labor.

Her cervix was long and closed, a long induction ensued, and after 36 hours of oxytocin induction with an epidural and two hours of pushing, she had a vaginal birth. After spontaneous delivery of an intact placenta, she hemorrhaged profusely. She required 6 units of packed red blood cells and was transferred to the ICU in unstable condition.

Comment:  This case also meets the definition for severe maternal morbidity and should undergo multidisciplinary review. Furthermore, this outcome is not due to the patient’s underlying medical condition and therefore meets the criteria for a Joint Commission sentinel event.  

 

Example #4

A woman at 39 weeks 2 days underwent a scheduled repeat cesarean birth and, during the procedure, is noted to have multiple premature ventricular contractions on the cardiac monitor. She was admitted to the ICU for cardiac monitoring for 24 hours and received no further treatment. 

Comment: This case meets the screening criteria for severe maternal morbidity and should be subject to a multidisciplinary review to determine the facts.  But as the case appears not to have led to “severe temporary harm,” it would not meet the criteria for a sentinel event.

References

  1. The Joint Commission. Comprehensive Accreditation Manual for Hospitals, Update 2, January 2015: Sentinel Events: SE-1. Available at: http://www.jointcommission.org/assets/1/6/CAMH_24_SE_all_CURRENT.pdf
  2. Callaghan WM, Grobman WA, Kilpatrick SJ, Main EK, D’Alton MD. Facility-Based Identification of Women With Severe Maternal Morbidity: It's Time to Start. Obstet Gynecol 2014;123:978-81.
  3. Callaghan WM, Grobman WA, Kilpatrick SJ, Main EK, D’Alton MD. Facility-Based Identification of Women With Severe Maternal Morbidity: It's Time to Start: Reply to Letter. Obstet Gynecol 2014; 124(3):634-635.
  4. Kilpatrick SJ, Berg C, Bernstein P, Bingham D, Delgado A, Callaghan WM, Harris K, Lanni S, Mahoney J, Main E, Nacht A, Schellpfeffer M, Westover T, Harper M.  Standardized Severe Maternal Morbidity Review: Rationale and Process.  Obstet Gynecol 2014;124:361-6.
  5. Sample severe maternal morbidity review forms available at: http://www.safehealthcareforeverywoman.org/get-smm-forms.php 
    accessed January 27, 2015.

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of approximately 58,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org

The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) is the foremost nursing authority that advances the health care of women and newborns through advocacy, research and the creation of high quality, evidence-based standards of care. AWHONN represents the interests of 350,000 registered nurses working in women's health, obstetric and neonatal nursing nationwide. AWHONN's 24,000 members worldwide are clinicians, educators and executives who serve as patient care advocates focusing on the needs of women and infants. A leader in professional development, AWHONN holds the distinction of receiving the Premier Program award by the American Nurses Credentialing Center (ANCC) for innovation and excellence in Continuing Nursing Education (CNE) three times. Founded in 1969 as the Nurses Association of the American College of Obstetrics and Gynecology, the association became a separate nonprofit organization called the Association of Women's Health, Obstetric and Neonatal Nurses in 1993. Visit AWHONN on Facebook.

Founded in 1951, The Joint Commission seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. The Joint Commission accredits and certifies more than 20,500 health care organizations and programs in the United States, including hospitals and health care organizations that provide ambulatory and office-based surgery, behavioral health, home care, laboratory and nursing home services. An independent, not-for-profit organization, The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in health care. The Joint Commission has two nonprofit affiliate organizations: The Joint Commission Center for Transforming Healthcare aims to solve health care’s most critical safety and quality problems and Joint Commission Resources (JCR) provides consulting services, educational services and publications. Joint Commission International, a division of JCR, accredits and certifies international health care organizations. Learn more about The Joint Commission at www.jointcommission.org.

The Society for Maternal-Fetal Medicine (est. 1977) is the premiere membership organization for obstetricians/gynecologists who have additional formal education and training in maternal-fetal medicine.  The society is devoted to reducing high-risk pregnancy complications by sharing expertise through continuing education to its 2,000 members on the latest pregnancy assessment and treatment methods. It also serves as an advocate for improving public policy, and expanding research funding and opportunities for maternal-fetal medicine. The group hosts an annual meeting in which groundbreaking new ideas and research in the area of maternal-fetal medicine are shared and discussed.  For more information visit www.smfm.org.

American Congress of Obstetricians and Gynecologists
409 12th Street SW, Washington, DC  20024-2188 | Mailing Address: PO Box 70620, Washington, DC 20024-9998