Joint Commission of the Accreditation of Healthcare Organizations
Confidential Enquiry Into Unexpected Sudden Deaths in Infancy
Why Train in Fetal Monitoring?
Inconsistent Interpretation & Communication of Abnormal Fetal Trends
JCAHO Sentinel Event Alert in 2004, "Preventing Infant Death and Injury During Delivery" found: 77% of all deaths or permanent disabilities in the sample group exhibited non-reassuring fetal status. Among the major root causes were communications, training and inadequate fetal monitoring.
The 1997 Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) found that: 75% of deaths during birth are due to human error. Misinterpretation of the fetal trace was the commonest failing.
Avoidable Poor Outcomes Increase Litigation & Cost
ACOG Poll in 2004 indicated:
- 76% of all OB/GYNs have been sued.
- Median lawsuit awarded $2.5million.
- Insurance Premiums Skyrocket.
The Answer is Training
- Develop clear guidelines for fetal monitoring of potential high-risk patients, including nursing protocols for the interpretation of fetal heart rate tracings.
- Educate nurses, residents, nurse midwives and physicians to use standardized terminology to communicate abnormal fetal heart rate tracings.