New Sentinel Event Alert
- 1/29/2010
- Author: Jim Parker
- Category: Perspectives on Patient Safety Blog
- 1902 Views
- 0 Comments
Be sure to read the new Sentinel Event Alert on preventing death during or after pregnancy, released by The Joint Commission on January 26.
Published for Joint Commission accredited organizations and interested health care professionals, Sentinel Event Alert identifies specific sentinel events, describes their common underlying causes, and suggests steps to prevent future occurrences.
This new alert addresses the heartbreaking issue of maternal mortality (deaths that occur within 42 days of birth or termination of pregnancy). Recent evidence indicates that maternal death rates in the United States may be on the rise. Since 1996, a total of 84 cases of maternal death have been reported to The Joint Commission’s sentinel event database, with the largest numbers of events reported in 2004, 2005 and 2006.
The alert cites data from the National Center for Health Statistics that places national maternal mortality rate in 2006 at 13.3 deaths per 100,000 live births. (2006 is the most recent year for which data were available.)
While it is possible that these numbers are the result of increased reporting of maternal deaths rather than an increase in the actual incidence, experts who contributed to the alert point out that the number of maternal deaths has certainly not declined in recent years.
According to the Sentinel Event Alert, the leading causes of maternal death include hemorrhage, hypertensive disorder, pulmonary embolism, amniotic fluid
embolism, infection, and pre-existing chronic conditions (such as cardiovascular disease).
Click here to read to full Sentinel Event Alert.
Perspectives on Patient Safety covered the issue of maternal death in the February 2009 issue, Subscribers can revisit that article here.
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