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. 2022 Feb 5;2(2):100038.
doi: 10.1016/j.xagr.2021.100038. eCollection 2022 May.

Missed anti-D immune globulin administration to postpartum patients in 2 health systems: an unrecognized patient safety risk

Kerri Brackney  1 , Gabriel Labbad  2 , Alyssa Hersh  3 , Monica Rincon  3 , David Bar-Shain  2 , Ray Babb  1 , Kelly S Gibson  1
Affiliations

Missed anti-D immune globulin administration to postpartum patients in 2 health systems: an unrecognized patient safety risk

Kerri Brackney et al. AJOG Glob Rep. .

Abstract

Background: Maternal-fetal Rh-alloimmunization is a rare but potentially fatal event, most often caused by maternal exposure to D-antigen-presenting Rh-positive erythrocytes at the time of delivery. Prophylaxis with anti-D immune globulin is highly effective with a low side-effect profile and results in a dramatically decreased risk of alloimmunization. Postpartum anti-D immune globulin prophylaxis is recommended by national societies to reduce Rh-alloimmunization. We hypothesized that a small number of postpartum patients do not receive prophylaxis as indicated. .

Objective: We investigated patients in 2 separate health systems that did not receive indicated prophylaxis and devised a suite of Electronic Health Record interventions to prevent future errors.

Study design: We reviewed charts retrospectively from Electronic Health Record data of 2 urban academic health systems, the MetroHealth System and Oregon Health & Science University. We identified all Rh-negative postpartum patients and their infants delivering from 2014 to 2019. The primary outcome was the proportion of postpartum patients not receiving indicated anti-D immune globulin prophylaxis. Once cases of missed anti-D immune globulin prophylaxis were identified, we reviewed individual charts to determine the relevant clinical circumstances and potential causes for error.

Results: Of 29,801 deliveries over 5 years (15,444 at MetroHealth System and 14,357 at Oregon Health & Science University), there were 3087 Rh-negative postpartum patients, of whom 7 were alloimmunized and ineligible for prophylaxis. Anti-D immune globulin was indicated for 2162 (70.0%) women as they delivered an Rh-positive infant. A total of 37 indicated patients did not receive postpartum anti-D immune globulin. Twenty patients were offered prophylaxis and declined. We missed a total of 17 opportunities, thus our institutions appropriately offered indicated anti-D prophylaxis to 99.2% of patients over a period of 5 years. Of the 17 true misses, anti-D immune globulin was ordered for some patients, whereas others did not have an anti-D immune globulin order placed. A toolkit in the Electronic Health Record consisting of decision-support hard stops, automated documentation, and longitudinal reporting was implemented at the MetroHealth System in the year after its inception. The Toolkit identified and helped prevent 4 potential misses, resulting in a 100% anti-D prophylaxis rate at the MetroHealth System.

Conclusion: Given the serious nature of Rh-alloimmunization, we believe missed prophylaxis should be a never event. Through examination of our current processes, we identified areas of improvement and developed a Postpartum Anti-D Immune Globulin Prophylaxis Electronic Health Record Toolkit, which showed improvement in administration rates. Such a toolkit has the potential to identify patients appropriately and avoid missed anti-D immune globulin prophylaxis events.

Keywords: anti-D immunoglobulin; electronic health record toolkit; maternal-fetal alloimmunization; missed prophylaxis; never event; obstetrical informatics; obstetrical quality improvement; rhesus immunoglobulin prophylaxis.

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Figures

Figure 1
Figure 1
Diagram of the MetroHealth System postpartum RHIG prophylaxis workflow The RHIG toolkit unobtrusively integrates into current workflows. RHIG, anti-D immune globulin.
Figure 2
Figure 2
Screenshot showing the automatic documentation phrase (Epic SmartPhrase) as used in a progress note The SmartPhrase displays the patient's blood type, the baby's blood type, and the patient's current RHIG prophylaxis status. We estimate a reduced documentation burden of approximately 27 seconds per patient with the use of the SmartPhrase. RHIG, anti-D immune globulin.
Figure 3
Figure 3
Sample interruptive BPA for patients over due for RHIG BPA, Best Practice Advisory; RHIG, anti-D immune globulin.
Figure 4
Figure 4
Sample Interruptive BPA for patients without indicated RIHG at discharge BPA, Best Practice Advisory; RHIG, anti-D immune globulin.
See this image and copyright information in PMC

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