Improved communication could reduce infant deaths

AORN Journal,  Oct, 2004  

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Better communication among caregivers could reduce the risk of infant deaths during delivery in hospitals, according to a July 22, 2004, news release from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). A study of infant deaths and major injuries reported through JCAHO's health care errors database found that almost 75% of hospitals cited communication breakdowns as a major factor in infant deaths. Specific communication issues included a lack of teamwork, not following the chain of communication, and an atmosphere that discourages team members from speaking up. Other root causes of infant deaths included lack of staff competency and training, inadequate fetal monitoring, and unavailability of monitoring equipment and medications.

Based on these findings, JCAHO issued an alert to more than 4,500 accredited hospitals to create new awareness of the problem and offer practical solutions for reducing the risk of infant deaths and major injuries. The alert recommends that hospitals take the following actions.

* Conduct formal team training sessions for obstetrical and perinatal team members.

* Use care guidelines established by the American Academy of Pediatrics; the American College of Obstetricians and Gynecologists; and the Association of Women's Health, Obstetric and Neonatal Nurses.

* Develop clear procedures for fetal monitoring of potential high-risk patients.

* Make sure that key personnel are available for emergency interventions.

* Ensure that neonatal resuscitation areas are appropriately equipped and functioning.

Joint Commission Issues Alert: Caregiver Communication Key to Preventing Infant Deaths (news release, Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations, July 22, 2004) http://www.jcaho.org/news+room/news+release+archives/nr_sea30.htm (accessed 3 Aug 2004).

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