Date of Graduation

Summer 8-5-2020

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)



Problem: Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality worldwide (Main et al., 2015). The national incidence of PPH is estimated at approximately 3% of all births (Marshall et al., 2018). A data analysis conducted in a maternal child health (MCH) department showed the total rate of PPH in 2019 was 10.8%. The incidence of PPH within this microsystem is significantly above the national average, indicating there is a substantial disparity in the care provided.

Context: An analysis of the MCH department showed an eagerness for change concerning PPH. The MCH staff have voiced safety concerns and inquiries regarding the disproportionate number of PPHs within the microsystem. Providers are treating more obstetrical hemorrhage emergencies and managing longer lengths of stay for their patients. Financially, the budget has been affected. The SWOT analysis and ROI assessment proved this quality improvement project to be beneficial in closing the quality gap.

Intervention: The project implemented the use of an evidence-based standardized debriefing tool to use after every PPH. The tool has been adapted from the California Maternal Quality Care Collaborative Postpartum Hemorrhage Toolkit. The debrief will include all members of the care team involved in the PPH. This debrief will be facilitated by the assistant nurse manager on shift during the hemorrhage. Once completed, the debrief tool will be collected by the PPH taskforce members and will be reviewed at every bi-monthly meeting.

Measures: The process measures of the project include the ANM on unit facilitating the debrief will all members of the care team. Once completed, the debrief sheets are filed in a confidential box for the PPH Task Force members to collect and review. Balancing measures include inability of all members of the care team being present for the debrief leading to inaccurate debrief details; lack of time to complete debrief post critical event; and staffing issues leading to the absence of a debrief facilitator.

Results: The test period began February 1, 2020, and finished April 30, 2020. The goal of 40% debrief rate was achieved two out of three months; however, the overall debrief percentage was 32% which falls below the aim percentage. Additionally, the PPH rate remained steady over the first two months of the test period and then increased during the final month. The average PPH rate during the test period was 9.4%.

Conclusion: The benefits of utilizing the PPH debrief tool were attained. In review of each completed debrief form, systems issues and practice improvements were identified. The information provided has led to the discovery of trends allowing for early identification of patients who may hemorrhage. The debriefs have had a positive response from the staff and have showed improvement in team dynamics. The PPH taskforce will continue to utilize the PPH debrief tools to promote evidenced-based care practices and ensure that the MCH department provides the highest level of care to every patient it serves.