Connie Christian, MBA, CPHRM
Facility Risk Management and Patient Safety Advisor

KAMMCO insureds care for pregnant and postpartum women in many settings and under several different specialty designations. The Joint Commission recently released Sentinel Event Alert 66 and a companion alert, Quick Safety Alert 67. They are both “must-read” for our healthcare providers who care for pregnant patients.

Sentinel Event Alert 66 identifies the need for eliminating racial and ethnic disparities causing mortality and morbidity in pregnant and postpartum patients.

Quick Safety Alert 67 addresses mental health conditions and their role in maternal death.

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To review the complete list of Joint Commission Sentinel Event Alerts, visit www.jointcommission.org/resources/sentinel-event/sentinel-event-alert-newsletters/#

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Key Information and Statistics from the Alerts

• The U.S. has the highest mortality rate for pregnant and postpartum patients among developed countries.

• A review of pregnancy-related deaths in 36 U.S. states determined that 80% were preventable.

• The following are pregnancy-related mortality rates for people by race per 100,000 live births:
  • Non-Hispanic Black = 55.3
  • Non-Hispanic White = 19.1
  • Hispanic = 18.2

• Perinatal depression is one of the most common medical complications during pregnancy and the postpartum period, affecting 1 in 7 patients.

• Perinatal depression is underdiagnosed and under-treated, with only 12% of affected pregnant patients receiving mental healthcare in the prior year.

• A study looked at 1,018 pregnancy-related deaths from 36 states and identified an underlying cause for 987 of them. The top underlying causes include mental health conditions (22.7%), hemorrhage (13.7%), coronary conditions (12.8%), infection (9.2%), thrombotic embolism (8.7%), and cardiomyopathy (8.5%).

• Social determinants of health are the social and economic conditions that affect health status and outcomes. These determinants include:
  • Housing and food insecurity
  • Lack of access to healthcare
  • Lack of health insurance
  • Lack of transportation
  • Low income
  • Education level
  • Racism, stereotyping, and discrimination

Joint Commission Recommendations

Find the full details of these recommendations in Sentinel Event Alert 66.

1. Encourage access to prenatal care.
2. During prenatal care, screen patients for hypertension, risk of hemorrhage, and other medical, socioeconomic, and mental health disorders risk factors.
3. Provide support and options that meet the needs and expectations of patients, including those who wish to deliver in a home or birthing center environment, while managing their risk of pregnancy complications.
4. Prepare for the possibility of hemorrhage and other complications.
5. Implement performance standards and improvement initiatives in every unit and provider practice.
6. Address unconscious biases of healthcare providers toward people of color through universal training.

Med-IQ Course

For more education on eliminating racial and ethnic disparities, visit the Med-IQ online learning platform on the KAMMCO website and take the Equity vs. Equality: Examining Implicit Bias through a Risk Management Lens course.