The Perinatal Safety Project: New Can Be Great!

Although in 2000, the frequency of birth injury claims filed in the Kaiser Permanente Northern California Region (KPNC) had remained stable for years, their cost had risen dramatically. In response to this trend, the KP Board of Directors assigned Bruce Merl, MD, Director of The Permanente Medical Group (TPMG) Medical-Legal Affairs, and Julie Nunes, KPNC Regional Risk Management Director, the task of reducing the cost of these claims. Also assembled to address this problem was an expert group consisting of Susan Smarr, MD (obstetrician and Assistant Physician-in-Chief for Risk at the KP Santa Clara Medical Center), Robin Field, MD (perinatologist at the KP San Francisco Medical Center), Sonia SooHoo, MD (obstetrician and Chief of Medical-Legal Affairs at the KP South San Francisco Medical Center), and Mary Parks (KPNC Senior Counsel for Professional Liability). They performed an in-depth analysis of both the literature and the KPNC experience regarding perinatal events. Risk strategies developed from these efforts were highlighted at a Medicine Today broadcast in 2001. A theme that emerged from this analysis was the integral role of communication and teamwork in successfully managing obstetric emergencies. Sidebar 1. PPSP Innovations are Big Steps Forward PPSP is being adopted Programwide. Teams are being identified in all KP Regions. A Critical Events Team Training (CETT) Train-the-Trainer program was offered in 2004 in the KP Southern California Region. Several KP Regions are purchasing mannequins in preparation for the training. A Fetal Heart Rate training video has been developed for Programwide dissemination to standardize language and interpretation of fetal heart rate tracings.