TMC PULSE

t m c » p u l s e | j u n e 2 0 1 7 13 C hildren's Memorial Hermann Hospital and McGovern Medical School at The University of Texas Health Science Center at Houston recently partnered with the March of Dimes to establish the first research center in the country dedicated to improving maternal and infant safety and preventing unnecessary illness and death. The March of Dimes Perinatal Safety Center is designed to identify sources of patient harm and develop techniques and training tools to minimize human error and close the gaps in health care through pregnancy, labor, delivery, postnatal care and the transition home. The institutions will use the information gathered to develop a blueprint for best practices that other hospitals around the country can implement. The research initiative is funded by a three-year, $2 million grant from the Gordon and Betty Moore Foundation and the Joe Kiani/Masimo Corporation to the March of Dimes. It will not occupy a designated space; rather, everyone involved will collaborate from their existing offices and facilities. "We certainly know that a lot of hospitals, like Children's Memorial Hermann and many other hospitals, do a fantastic job of taking care of patients and babies when they're here, support- ing the families that are here," March of Dimes president Stacey D. Stewart said. "But like a lot of other industries, everyone's always interested in how you can do better, how you can improve the outcomes and how you can make sure that every baby is as safe as possible. There's no room for error." While it's important for hospitals to be highly reliable, "it's easier said than done," said the center's principal investigator, KuoJen Tsao, M.D., the Children's Fund, Inc. Distinguished Professor in Pediatric Surgery at McGovern Medical School and co-director of The Fetal Center at Children's Memorial Hermann Hospital. "Our ultimate goal is to really improve the culture of patient safety," Tsao said. "We think we are a safe orga- nization. We think we do everything safely. But can we measure it so we identify the hot spots and how to make it better?" Children's Memorial Hermann delivers more than 5,200 babies and performs close to 5,800 pediatric sur- geries every year. The hospital offers more than 40 maternal and pediatric specialties—including high-risk preg- nancy, NICU and neonatal care and pediatric trauma—and has one of only four Level IV NICUs in the state to care for the most critically ill babies. Throughout a mother's pregnancy, labor and delivery, she typically tran- sitions from outpatient care with her primary OBGYN doctors to inpatient care with a team of delivery specialists at the hospital. Once the baby is born, mother and child are handed off to another team of neonatal specialists. The various teams of specialists work- ing in silos can lead to blind spots and barriers within the health care system that can create medical errors along the way. "We know that once you hit the hos- pital, you are taken care of … by people, and people make mistakes," Tsao said. "We usually have systems for obstetri- cians or systems for the NICU, but it's really about creating one entire system for two patients from the beginning." The journey through the hospital system can be even more complicated for premature babies who require extra care. On average, a premature baby will stay in the NICU for four months, according to Amir Khan, M.D., med- ical director of Children's Memorial Hermann Hospital NICU and admin- istrative director of neonatology at McGovern Medical School. "You have to do everything right every day for 120 days, which basically means you have to make sure that the … 20 to 30 nurses, about five to six doctors and a whole bunch of other people are trained enough to take care of that spe- cific baby for that period of time," Khan said. "Sustaining it is the hardest part. One mistake can result in a very, very bad outcome." (continued) For Mothers and Babies, Safety First A first-of-its-kind research center devoted to perinatal safety launches at the medical center B y S h a n l e y C h i e n Premature babies, including Addison Clark, above, born 1 lb. 4 oz. at 23 weeks, will benefit from the new March of Dimes Perinatal Safety Center. Our ultimate goal is to really improve the culture of patient safety. We think we are a safe organization. We think we do everything safely. But can we measure it so we identify the hot spots and how to make it better? — KUOJEN TSAO, M.D. Principal investigator for the March of Dimes Perinatal Center

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