Pre-identified quality issues: successes, latent safety hazards, and change interventions
| Component | Successes | Latent safety hazards (identified by direct observation or debriefing) | Change interventions |
|---|---|---|---|
| TIP CPG: Pre-hospital and ED care | Appropriate implementation of Pre-hospital TTA Maternal positioning, investigations Fetal assessment equipment Appropriate use of CPG Switchboard support to call consultants | Unclear TTA criteria Drug doses in pregnancy not specified Physician CPG not specific enough | Clarification of TTA criteria on CPG Pregnancy-appropriate drug doses added to CPG Physician CPG revised |
| TIP CPG: OR care | Appropriate support of BCWCH MFM/neonatology Accessible by phone in a timely manner THAU nurses to bring supplies/medications | Unclear maternal/neonatal hospital transfer criteria Difficulty accessing all delivery medications Inconsistent caesarean section training among all trauma surgeons | Clarification of transfer criteria on CPG Delivery medication “kits” now stocked in ED, ICU, OR and THAU Trauma surgeons to develop strategy for skill maintenance |
| Code Pink algorithm | Appropriate use of Algorithm to guide care of unfamiliar situation Multidisciplinary consultants as recommended | Improperly stocked infant warmer Inconsistent neonatal resuscitation training among Code Pink nurses Lack of clarity about anesthesia involvement at Code Pink | Monthly checks by Code Pink team On-site neonatal resuscitation training program implemented for Code Pink nurses Multi-departmental commitment for anesthesia at all Code Pink |
BCWCH = British Columbia Women’s and Children’s Hospital; CPG = clinical practice guideline; ED = emergency department; ICU = intensive care unit; MFM = maternal-fetal medicine; OR = operating room; THAU = trauma high-acuity unit; TIP = trauma in pregnancy; TTA = trauma team activation.