A Multidisciplinary Model for Reviewing Severe Maternal Morbidity Cases and Teaching Residents Patient Safety Principles

Jt Comm J Qual Patient Saf. 2019 Jun;45(6):423-430. doi: 10.1016/j.jcjq.2019.02.003. Epub 2019 Mar 21.


The Joint Commission recommends that severe maternal morbidity (SMM) cases involving peripartum ICU admissions and blood transfusion > 4 units undergo systematic reviews to determine opportunities for improvement in care. This article describes a retrospective study of an SMM multidisciplinary committee review using a published template.

Methods: Residents attend a patient safety and quality improvement (PSQI) course at orientation, learn in serial PSQI educational sessions, and receive individual training on the SMM review. The multidisciplinary SMM review process determines contributory factors, identifies best practices, recognizes care improvement opportunities, and facilitates adoption of appropriate interventions. How the process educated residents on the Clinical Learning Environment Review (CLER) focus areas was explored.

Results: From January 2015 to June 2017, 45 SMM cases were reviewed. Reviewers were primarily residents/fellows (64.4% of cases), nurses (11.1%), and maternal-fetal medicine faculty (24.4%). Transfusion > 4 units occurred in 44.4% of cases, and ICU admission in 68.9%. Causes of SMM included obstetric bleeding (57.8%), hypertensive crisis (42.2%), and cardiac disease (24.4%). Preterm delivery occurred in 60.0% of cases; 71.1% were postpartum, and 80.0% had cesarean deliveries. Contributory provider factors included diagnostic delays (55.6%) and treatment delays or errors (44.4%). Contributory patient factors included psychiatric/behavioral health (20.0%) and health care barriers (22.2%). Morbidity could have been prevented by provider factors in 53.3% of cases and by patient factors in 37.8%. Interventions initiated included recruiting a safety nurse, TeamSTEPPS® training, and adoption of hypertension and postpartum hemorrhage safety bundles.

Conclusion: SMM reviews can be successfully implemented and provide training on safety and quality.

MeSH terms

  • Female
  • Humans
  • Internship and Residency*
  • Models, Educational
  • Obstetrics / education*
  • Patient Safety*
  • Pregnancy
  • Pregnancy Complications / prevention & control*
  • Quality Improvement*
  • Retrospective Studies