Implementation and Evaluation of the Obstetric Hemorrhage Patient Safety Bundle


Name: Lisa Osborne

Rank: CAPT

Organization: Henry M. Jackson Foundation for the Advancement of Military Medicine

Performance Site: Ft. Belvoir Community Hospital, Ft. Belvoir, VA; Uniformed Service University of the Health Sciences, Bethesda, MD

Year Published: 2015

Abstract Status: Project Completed


This project is an implementation program to be conducted at Ft. Belvoir Community Hospital. The goal of the project is to improve the readiness, recognition and response to obstetric hemorrhage through the implementation of a patient safety bundle that has been approved by the DoD Perinatal Quality and Safety Work-group. The implementation of this set of guidelines is complex because it is a full "bundle" of recommendations. Successful implementation will require the development a highly functioning multidisciplinary team that can respond effectively to the emergency obstetrical situation. Adding to the complexity is the need to address the lack of resources, such as an in-house blood bank at this size of institution, and the requirement for in-house practice drills. This project is a novel approach to implementing this patient safety bundle, and will be supported by collaborative efforts of an inter-professional team consisting of Tri-Service clinical staff at Ft. Belvoir and faculty from the Uniformed Services University. The phases of implementation include familiarization of the bundle components, assessment of the current state of practice, adaptation of tools to fit the unit, development of a unit-specific algorithm for activation and response of the team, and implementation and evaluation of the response. Critical to this process will be the development of unit drills to identify systems problems that interfere with the ability of the team to provide rapid, coordinated care. Facilitation of the unit drills and the debriefing process is a large focus of this project.  Debriefing after the drills will focus on systems learning to promote open dialogue and influence the culture of learning. In both instances, TeamSTEPPS will be used to improve communication and teamwork skills among the healthcare team. All of these elements taken together provide a comprehensive implementation plan for this patient safety guideline. This EBP Project will serve as a model to facilitate guideline implementation DoD-wide and improve outcomes related to obstetric hemorrhage.

This project is timely and extremely relevant because military hospitals will be required to implement this new patient safety bundle starting February 2015 in an effort to improve emergency response to obstetric hemorrhage. The implementation will need to be coordinated across disciplines with no educational gaps in the change process that could put patient safety at risk. The goal of this project is to improve patient safety and team functioning to provide the highest level of perinatal care.


Final Report is available on NTRL: