Infant deaths subject of new Sentinel Event Alert

Incidents of perinatal death or permanent disability have declined steadily in recent years, but the tragedy still occurs too often, reports the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). JCAHO’s most recent Sentinel Event Alert addresses this issue with recommendations for lowering the risk even further.

The entire Sentinel Event Alert is available on JCAHO’s web site at www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_30.htm. JCAHO notes that the rate of perinatal mortality in the United States has steadily declined to a rate of 6.9 deaths per 1,000 live births in 2001; but since the sentinel event reporting requirements began in 1996, a total of 71 cases of perinatal death or permanent disability have been reported.

Any perinatal death or major permanent loss of function "unrelated to a congenital condition in an infant having a birth weight greater than 2,500 g" must be reported as a sentinel event. Of the 71 reported cases, 61 resulted in infant deaths and 10 involved permanent disabilities. JCAHO reports that the mothers ranged in age from 13 to 41, with the average and median age being 27 years; and in just more than one-half of the cases, it was the first child. The average gestation was 39 weeks.

Contrary to what one might expect, a lack of prenatal care was an identified maternal risk factor in just 4% of cases. (The statistical analysis of the reports is based on only 47 of the 71 reported cases. JCAHO reports that it will release a complete statistical analysis soon.) Other identified maternal risk factors included age (13%), previous cesarean (11%), diabetes (4%), and substance abuse (4%).

Communication issues topped the list of identified root causes (72%), with more than one-half of the organizations (55%) citing organization culture as a barrier to effective communication and teamwork. Examples included hierarchy and intimidation, failure to function as a team, and failure to follow the chain of communication.

The reports also cited these root causes: staff competency (47%), orientation and training process (40%), inadequate fetal monitoring (34%), unavailable monitoring equipment and/or drugs (30%), credentialing/privileging/supervision issues for physicians and nurse midwives (30%), staffing issues (25%), physician unavailable or delayed (19%), and unavailability of prenatal information (11%).