The U.S. has double the maternal mortality rate compared to other developed nations, with postpartum hemorrhage being a major contributor to these deaths. Postpartum hemorrhage is defined as excessive blood loss within 24 hours of delivery or up to 12 weeks following delivery. This condition is treatable if identified and managed promptly, making understanding the safety culture factors critical to improving outcomes. The study highlights how organizational culture directly impacts clinical care during these emergencies. This comprehensive analysis offers actionable insights for transforming emergency response protocols nationwide.
By the numbers:
- 17 maternal deaths per 100,000 births in the U.S. (2018) — double the rate of comparable countries like France and Canada
- Researchers identified 45 barriers and 158 facilitators related to the existing safety culture of hospital systems related to postpartum hemorrhage care
How they did it:
The study used the Systems Engineering Initiative for Patient Safety (SEIPS) model to analyze how sociotechnical systems shape safety culture during postpartum hemorrhage emergencies. Researchers conducted intensive interviews and focus groups with 29 frontline clinicians, capturing real-world experiences that reveal the critical dynamics overlooked in traditional clinical literature but fundamental to patient survival.
Key findings:
The study identified five principal areas affecting safety culture during postpartum hemorrhage management:
- Staffing: Issues related to personnel availability, expertise, and distribution
- Communication: Information flow between team members during critical situations
- Organizational management and leadership: How leadership structures and decisions impact frontline care
- Organizational processes: Formal and informal procedures for handling emergencies
- Teamwork: Collaboration dynamics between different clinical specialties and roles
The bottom line:
Improving maternal outcomes requires a systems approach to safety culture. Rather than focusing on individual clinician performance, broader systems should be redesigned to address specific barriers in staffing, communication patterns, management structures and team dynamics and improve safety culture. This research provides a blueprint for maternal safety enhancement through targeted system redesign, focusing on the human and organizational factors that demonstrably impact clinical outcomes during postpartum emergencies.
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Abigail Woolridge is an Assistant Professor in the Department of Industrial and Enterprise Systems Engineering in the Grainger College of Engineering. Her interests include patient journey and safety, care transitions, and team cognition research.
Learn more about Wooldridge's work by visiting Human Factors in Sociotechnical Systems Laboratory.
Read the full journal article: https://pubmed.ncbi.nlm.nih.gov/40077061/