CSI Summary
Available only to registered AACN.org users.
Project Topic
Debriefing after critical events in Labor & Delivery and Obstetrics/Gynecology
CSI Participants
Myeva Brett, RN, BSN, RNC‐OB
Sharlene Degirolamo, RN, BSN, RNC‐OB
Melanie Irwin, RN, BSN
Leslie Loring, RN, BSN
Susanne Procopio, RN, BSN
Mia Taa‐White, RN, BSN
Jennifer Turney, RN, MSN, CNS, CPN
Project Goals/Objectives
- To develop a standardized debriefing process for critical events that increases quality of teamwork and improves patient outcomes
- To reduce the incidence of postpartum hemorrhage resulting in a massive transfusion (>4 units of blood) by a rate of 1.5 by December 2016
- To establish a baseline for critical event team dynamics, and identify opportunities for improvement
Project Outcomes
- Reduced the rate of postpartum hemorrhage events resulting in a massive transfusion to zero from July 2016 through December 2016
- Established a baseline for team performance during critical events
- These outcomes resulted in an estimated annual fiscal impact of $101,212
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Permission to Reuse Materials
The materials associated with this AACN Clinical Scene Investigator (CSI) Academy project are the property of the participating hospital noted above, not AACN. Requests to use content contained in the CSI team’s summary, presentation or toolkit should be directed to the hospital. We suggest reaching out to the hospital’s Communications, Marketing or Nursing Education department for assistance.
Disclaimer
The AACN CSI Academy program supports change projects based on quality improvement methods. Although CSI teams seek to ensure linkage between their project and clinical/fiscal outcomes, data cannot be solely attributed to the project and are estimations of impact.