A macroergonomic analysis to identify improvements to postpartum hemorrhage anticipation, identification, and management

Background: Postpartum hemorrhage (PPH) remains a leading cause of maternal mortality despite the development of interventions to optimize the diagnosis and management. In this study, we used models and methods from macroergonomics to understand why PPH remains a leading cause of maternal mortality. Specifically, we used the Systems Engineering Initiative for Patient Safety (SEIPS) model to explore how the work system during the anticipation, identification, and management of PPH can be redesigned to improve patient safety. Methods: We performed 26 observations of direct patient care, totaling 37 h and 36 min, to understand the care processes during the anticipation, identification, and management of PPH. We used the SEIPS-based process modeling method to visualize the care processes. Additionally, we conducted interviews and focus groups with 29 clinicians to understand the positive and negative factors that impact patient safety. We analyzed the interview and focus group transcripts using thematic content analysis to identify the positive and negative factors. Results: We developed a SEIPS-based process map of the anticipation, identification, and management care processes during a cesarean-section delivery and a vaginal delivery. Additionally, we identified 753 factors that positively or negatively impact the quality of care during the anticipation, identification, and management of PPH. We categorized these factors into 13 dimensions—role ambiguity, anticipation, physical environment, staffing, resources/equipment, tools and technology, communication, coordination, cooperation, tacit knowledge, time pressure, leadership, and training. Conclusion: Our findings resulted in four system design considerations to improve patient safety: assigning the coordination of clinicians and resources as a job function, integrating point-of-care tools, improving the lighting in the patient rooms, and redesigning the PPH risk assessment tool to support the anticipation, identification, and management of PPH.