Table 1

Pre-identified quality issues: successes, latent safety hazards, and change interventions

ComponentSuccessesLatent safety hazards (identified by direct observation or debriefing)Change interventions
TIP CPG: Pre-hospital and ED careAppropriate implementation of
 Pre-hospital TTA
 Maternal positioning, investigations
 Fetal assessment equipment
Appropriate use of
 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 careAppropriate 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 algorithmAppropriate 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.