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The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued an alert to accredited hospitals about the key role caregiver communications plays in preventing infant death and injury during delivery. In a review of 47 cases of perinatal death or permanent disability reported to JCAHO since 1996, it said the majority of reported root causes related to problems with organizational culture and with communication among caregivers.
In the alert, JCAHO recommends that organizations conduct team training in perinatal areas to teach staff to work together and communicate more effectively. It also recommends hospitals conduct clinical drills to help staff prepare for high-risk events such as emergency cesarean delivery and maternal hemorrhage when they occur, and debriefings to evaluate team performance and identify areas for improvement, among other steps. For more information, see "Sentinel Event Alert: Issue 30" at www.jcaho.org.