Development of a Tool to Measure Nurse Clinical Judgment During Maternal Mortality Case Review

2016 ◽  
Vol 45 (6) ◽  
pp. 870-877 ◽  
Author(s):  
Marla J. Seacrist ◽  
Danielle Noell
Keyword(s):  
Maternal Mortality ◽  
Clinical Judgment ◽  
Case Review ◽  
Mortality Case

scholarly journals Are morbidity and mortality case review practices in Scottish intensive care units aligned to national standards?

2017 ◽  
Vol 19 (3) ◽  
pp. 264-268
Author(s):  
Mohammed(Mo) Faik Al-Haddad ◽  
Andrew Cadamy ◽  
Euan Black ◽  
Kate Slade
Keyword(s):  
Intensive Care ◽  
Intensive Care Units ◽  
National Standards ◽  
Morbidity And Mortality ◽  
Case Review ◽  
Allied Health Professionals ◽  
Telephone Interviews ◽  
Significant Events ◽  
Mortality Case ◽  
Cardiac Intensive Care

Introduction Both Scottish and UK standards guidelines recommend that intensive care units should hold regular, structured, multidisciplinary morbidity and mortality meetings. The aim of this survey was to ascertain the nature of current practice with regards to morbidity and mortality case reviews and meetings in all intensive care units in Scotland. Methods Semi-structured telephone interviews were conducted with a consultant from all Scottish intensive care units. A list of intensive care units in Scotland was obtained from the Scottish Intensive Care Society Audit Group annual report. Results All 24 intensive care units (100%) in Scotland were surveyed. The interviews took an average of 20 min. The three cardiac intensive care units were excluded from analysis. All other intensive care units had morbidity and mortality meetings and 18 units had a morbidity and mortality clinical lead. Nineteen intensive care units held joint morbidity and mortality meetings, eight of which were regular. In all intensive care units, meetings were attended by consultants and trainees. In 14 intensive care units, meetings were attended by nurses, seven by allied health professionals, 1 by a manager and 11 by other professionals. All mortality cases in intensive care unit were discussed in 19 intensive care units, in the other two intensive care units, 10–20% of mortality cases were discussed. Conclusion There is a wide variation in the processes of reviewing mortality cases and significant events in intensive care units across Scotland, and in the way morbidity and mortality meetings are organised and held. Based on this survey, there is scope for improving the consistency of approach to morbidity and mortality case reviews and meetings in order to improve education and facilitate shared learning.

scholarly journals An innovative resident-driven mortality case review curriculum to teach and drive system-based practice improvements in the United States

2018 ◽  
Vol 15 ◽  
pp. 31
Author(s):  
Nila S. Radhakrishnan ◽  
Margaret C. Lo ◽  
Rohit Bishnoi ◽  
Subhankar Samal ◽  
Robert Leverence ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Systems Of Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Tertiary Care ◽  
The United States ◽  
Case Review ◽  
Failure To Rescue ◽  
Internal Medicine Residents ◽  
Mortality Case

Purpose: Traditionally, the morbidity and mortality conference (M&MC) is a forum where possible medical errors are discussed. Although M&MCs can facilitate identification of opportunities for systemwide improvements, few studies have described their use for this purpose, particularly in residency training programs. This paper describes the use of M&MC case review as a quality improvement activity that teaches system-based practice and can engage residents in improving systems of care. Methods: Internal medicine residents at a tertiary care academic medical center reviewed 347 consecutive mortalities from March 2014 to September 2017. The residents used case review worksheets to categorize and track causes of mortality, and then debriefed with a faculty member. Selected cases were then presented at a larger interdepartmental meeting and action items were implemented. Descriptive statistics and thematic analysis were used to analyze the results. Results: The residents identified a possible diagnostic mismatch at some point from admission to death in 54.5% of cases (n= 189) and a possible need for improved management in 48.0% of cases. Three possible management failure themes were identified, including failure to plan, failure to communicate, and failure to rescue, which accounted for 21.9%, 10.7 %, and 10.1% of cases, respectively. Following these reviews, quality improvement initiatives proposed by residents led to system-based changes. Conclusion: A resident-driven mortality review curriculum can lead to improvements in systems of care. This novel type of curriculum can be used to teach system-based practice. The recruitment of teaching faculty with expertise in quality improvement and mortality case analyses is essential for such a project.

scholarly journals Magnetic resonance imaging of traumatic injury to the craniovertebral junction: a case-based review

2015 ◽  
Vol 38 (4) ◽  
pp. E3 ◽  
Author(s):  
Anil K. Roy ◽  
_ _ ◽  
Brandon A. Miller ◽  
Christopher M. Holland ◽  
Arthur J. Fountain ◽  
...  
Keyword(s):  
Clinical Judgment ◽  
Clinical Decision Making ◽  
Spinal Column ◽  
Case Series ◽  
Craniovertebral Junction ◽  
Significant Heterogeneity ◽  
Case Review ◽  
Ligamentous Injury ◽  
Mri Findings ◽  
Retrospective Case

OBJECT The craniovertebral junction (CVJ) is unique in the spinal column regarding the degree of multiplanar mobility allowed by its bony articulations. A network of ligamentous attachments provides stability to this junction. Although ligamentous injury can be inferred on CT scans through the utilization of craniometric measurements, the disruption of these ligaments can only be visualized directly with MRI. Here, the authors review the current literature on MRI evaluation of the CVJ following trauma and present several illustrative cases to highlight the utility and limitations of craniometric measures in the context of ligamentous injury at the CVJ. METHODS A retrospective case review was conducted to identify patients with cervical spine trauma who underwent cervical MRI and subsequently required occipitocervical or atlantoaxial fusion. Craniometric measurements were performed on the CT images in these cases. An extensive PubMed/MEDLINE literature search was conducted to identify publications regarding the use of MRI in the evaluation of patients with CVJ trauma. RESULTS The authors identified 8 cases in which cervical MRI was performed prior to operative stabilization of the CVJ. Craniometric measures did not reliably rule out ligamentous injury, and there was significant heterogeneity in the reliability of different craniometric measurements. A review of the literature revealed several case series and descriptive studies addressing MRI in CVJ trauma. Three papers reported the inadequacy of the historical Traynelis system for identifying atlantooccipital dislocation and presented 3 alternative classification schemes with emphasis on MRI findings. CONCLUSIONS Recognition of ligamentous instability at the CVJ is critical in directing clinical decision making regarding surgical stabilization. Craniometric measures appear unreliable, and CT alone is unable to provide direct visualization of ligamentous injury. Therefore, while the decision to obtain MR images in CVJ trauma is largely based on clinical judgment with craniometric measures used as an adjunct, a high degree of suspicion is warranted in the care of these patients as a missed ligamentous injury can have devastating consequences.

Retrospective maternal mortality case ascertainment in West Virgina, 1985 to 1989

1992 ◽  
Vol 167 (1) ◽  
pp. 72-76 ◽  
Author(s):  
Timothy D. Dye ◽  
Howard Gordon ◽  
Berel Held ◽  
Nancy J. Tolliver ◽  
Alan P. Holmes
Keyword(s):  
Maternal Mortality ◽  
Case Ascertainment ◽  
Mortality Case ◽  
West Virgina

scholarly journals The influence of the using “near-miss” on some obstetric bleeging indicators

2018 ◽  
Vol 67 (1) ◽  
pp. 13-19
Author(s):  
Guldzhahon K. Davlyatova ◽  
Marhabo Ya Kamilova ◽  
Dilnoza M. Rakhmatulloeva
Keyword(s):  
Maternal Mortality ◽  
Medical Care ◽  
Near Miss ◽  
Maternal Near Miss ◽  
Case Review ◽  
Maternity Hospitals ◽  
Implementation Of Standards

The article reviews the use of maternal near-miss in maternity hospitals of Tajikistan and its effect on selected indicatior of maternal bleedings. The implementation of standards and the use of near miss case review in 20 maternity hospitals was shown to decrease the rate of maternal bleedings, especially hypotonic bleedings, the rate of critical hypotonic bleedings, the rate of hysterectomy, and the ratio between deaths due to maternal bleeding in these maternity hospitals and overall maternal bleeding mortality. Our results confirm, that the use of “near-miss” strategy improves the quality of maternal medical care and allows to decrease overall maternal mortality.

scholarly journals Maternal Mortality Due to an Undiagnosed Large Thymoma in Puerperium: A Case Report

2021 ◽  
Vol 1 (1) ◽  
Author(s):  
Malihe Fakehi ◽  
Sara Saeidi ◽  
Maryam Mazloumi ◽  
Neda Hashemi ◽  
Maryam Rahimi ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Maternal Mortality ◽  
Anterior Mediastinum ◽  
Case Presentation ◽  
Puerperal Woman ◽  
Mortality Case ◽  
Recent Diagnosis ◽  
Changes In Pregnancy ◽  
Medical Referral ◽  
In Pregnancy

Introduction: Delayed or avoided medical care due to coronavirus disease 2019 (COVID-19) related concerns may increase morbidity and mortality associated with both acute and chronic health conditions. Thymoma is uncommon in pregnancy, although it could be accompanied with unfavorable outcomes. We report a puerperal woman presented with dyspnea and cardiac arrest with a recent diagnosis of thymoma that led to maternal mortality. Case Presentation: A 38-year-old woman with occasional dyspnea during pregnancy without medical referral was admitted to the hospital with severe dyspnea and orthopnea three days after cesarean section. Spiral computed tomography (CT) angiography showed a 64 × 84-centimeter mass with soft tissue density in the left perivascular that was originated from the anterior mediastinum; in biopsy, thymoma was suggested. She died shortly after due to severe dyspnea and cardiac arrest. Conclusions: Prenatal care during COVID-19 pandemic should not be postponed. Indeed, any symptom similar to the physiologic changes in pregnancy needs to be evaluated for optimal clinical management.

scholarly journals Analysis Determinants of Postpartum Maternal Mortality at Sidoarjo Regency in 2012

2014 ◽  
Vol 2 (1) ◽  
pp. 105
Author(s):  
Puspita Rahmawati ◽  
Santi Martini ◽  
Chatarina Umbul Wahjuni
Keyword(s):  
Multivariate Analysis ◽  
Maternal Mortality ◽  
Univariate Analysis ◽  
Maternal Mortality Ratio ◽  
Observational Research ◽  
Bivariate Analysis ◽  
Chi Square ◽  
Mortality Case ◽  
Mortality Ratio ◽  
Chi Square Test

ABSTRACTThe maternal mortality ratio (MMR) in Indonesia remains high, i.e approximately 359 per 100.000 life birth (IDHS 2012). MMR is an indicator of mother’s health, especially the risk of being death for a mother while pregnant and delivery. Mostly the majority of maternal mortality (MMR) is occurring in the first two days after delivery and care after giving birth services required to manage complication. Sidoarjo regency has high postpartum maternal mortality case, so it is necessary to study determinants influencing postpartum maternal mortality in that regency. This research aimed to analyze the determinants that influence postpartum maternal mortality. This research was an observational research using case control study. Number of samples was 21 cases and 43 controls. Data were analyzed by univariate analysis, bivariate analysis with chi-square test, and multivariate analysis with multiple logistic regressions. The result showed that the determinants which influence postpartum maternal mortality according to multivariate analysis were pre-eclampsia/eclampsia (OR = 20,98; 95%CI : 2,250 – 323,416; p = 0,008) and delivery complication (OR = 5,47; 95%CI : 1,356 – 22,022; p = 0,017). Probability of mother to have risk of postpartum maternal mortality with all those risk factors above was 92,9%. This research recommended are need to detect early sign of pregnancy, delivery, and post delivery complication, especially danger sign of pre-eclampsia/eclampsia, referral preparation, and pregnancy planning. Keywords :  postpartum maternal mortality, determinants, pre-                                     eclampsia/eclampsia, delivery complication.

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