For women who are identified as being at high risk because of existing conditions such as high blood pressure, diabetes or morbid obesity, the Alert calls for referrals to experienced prenatal care providers who can provide specialized services. In order to avoid pulmonary embolism, The Joint Commission urges hospitals to make pneumatic compression devices available to high-risk patients undergoing a Cesarean section. Finally, hospitals are urged to evaluate whether pregnant women who are at high risk for dangerous blood clots (thromboembolism) should receive a special dosage of blood thinner after giving birth.

In addition to the specific recommendations contained in the Alert, the Joint Commission urges hospitals to use its accreditation standards to improve safety for pregnant women. The standards require hospitals to have a process for recognizing and responding as soon as a patient's condition appears to be worsening, and to develop written criteria for early warning signs that a patient's condition is deteriorating. The standards also address staff response to concerns about a patient's condition and educating patients and families about how to get help if they have concerns.

The warning about maternal deaths is part of a series of Alerts issued by the Joint Commission. Much of the information and guidance provided in these Alerts is drawn from The Joint Commission's Sentinel Event Database, one of the nation's most comprehensive voluntary reporting systems for serious adverse events in health care. Previous Alerts have addressed health care technology, anticoagulants, wrong-site surgery, medication mix-ups, health care-associated infections, and patient suicides, among others. The complete list and text of past issues of Sentinel Event Alert can be found at jointcommission/SentinelEvents/SentinelEventAlert/.

SOURCE: The Joint Commission