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JCAHO
Joint Commission of the Accreditation of Healthcare Organizations
CESDI
Confidential Enquiry Into Unexpected Sudden Deaths in Infancy

K2 are dedicated to improving maternity care. Our Fetal Monitoring Training System is 5 years in the making.

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.

Risk Management Fnd of Harvard Medical Inst found: most frequent allegation in perinatal malpractice claims is delayed diagnosis of fetal distress.

The Answer is Training

JCAHO Recommendation:

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.