Obstetrical hemorrhage reporting and systems learning

Abstract

Reporting and systems learning provide the backbone for a sustainable comprehensive response to maternal hemorrhage. Reporting back to the institution requires capturing various elements such as compliance, results of debriefs, and comprehensive reviews of cases where there has been severe maternal morbidity. The system then learns from these reviews, and modifies as necessary any areas not performing as desired. Compliance monitoring, aside from review of an adverse event, is also an essential element of the reporting process by assessing for drift, returning to pre-implementation practices.