Missed anti-D immune globulin administration to postpartum patients in 2 health systems: an unrecognized patient safety risk

BACKGROUND: Maternal-fetal Rh-alloimmunization is a rare but potentially fatal event, most often caused by maternal exposure to D-antigen-presenting Rh-positive erythrocytes at the time of delivery. Prophylaxis with anti-D immune globulin is highly effective with a low side-effect profile and result...

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Bibliographic Details
Main Authors: Babb, R. (Author), Bar-Shain, D. (Author), Brackney, K. (Author), Gibson, K.S (Author), Hersh, A. (Author), Labbad, G. (Author), Rincon, M. (Author)
Format: Article
Language:English
Published: Elsevier Inc. 2022
Subjects:
Online Access:View Fulltext in Publisher
LEADER 04018nam a2200301Ia 4500
001 10.1016-j.xagr.2021.100038
008 220630s2022 CNT 000 0 und d
020 |a 26665778 (ISSN) 
245 1 0 |a Missed anti-D immune globulin administration to postpartum patients in 2 health systems: an unrecognized patient safety risk 
260 0 |b Elsevier Inc.  |c 2022 
520 3 |a BACKGROUND: Maternal-fetal Rh-alloimmunization is a rare but potentially fatal event, most often caused by maternal exposure to D-antigen-presenting Rh-positive erythrocytes at the time of delivery. Prophylaxis with anti-D immune globulin is highly effective with a low side-effect profile and results in a dramatically decreased risk of alloimmunization. Postpartum anti-D immune globulin prophylaxis is recommended by national societies to reduce Rh-alloimmunization. We hypothesized that a small number of postpartum patients do not receive prophylaxis as indicated. OBJECTIVE: We investigated patients in 2 separate health systems that did not receive indicated prophylaxis and devised a suite of Electronic Health Record interventions to prevent future errors. STUDY DESIGN: We reviewed charts retrospectively from Electronic Health Record data of 2 urban academic health systems, the MetroHealth System and Oregon Health & Science University. We identified all Rh-negative postpartum patients and their infants delivering from 2014 to 2019. The primary outcome was the proportion of postpartum patients not receiving indicated anti-D immune globulin prophylaxis. Once cases of missed anti-D immune globulin prophylaxis were identified, we reviewed individual charts to determine the relevant clinical circumstances and potential causes for error. RESULTS: Of 29,801 deliveries over 5 years (15,444 at MetroHealth System and 14,357 at Oregon Health & Science University), there were 3087 Rh-negative postpartum patients, of whom 7 were alloimmunized and ineligible for prophylaxis. Anti-D immune globulin was indicated for 2162 (70.0%) women as they delivered an Rh-positive infant. A total of 37 indicated patients did not receive postpartum anti-D immune globulin. Twenty patients were offered prophylaxis and declined. We missed a total of 17 opportunities, thus our institutions appropriately offered indicated anti-D prophylaxis to 99.2% of patients over a period of 5 years. Of the 17 true misses, anti-D immune globulin was ordered for some patients, whereas others did not have an anti-D immune globulin order placed. A toolkit in the Electronic Health Record consisting of decision-support hard stops, automated documentation, and longitudinal reporting was implemented at the MetroHealth System in the year after its inception. The Toolkit identified and helped prevent 4 potential misses, resulting in a 100% anti-D prophylaxis rate at the MetroHealth System. CONCLUSION: Given the serious nature of Rh-alloimmunization, we believe missed prophylaxis should be a never event. Through examination of our current processes, we identified areas of improvement and developed a Postpartum Anti-D Immune Globulin Prophylaxis Electronic Health Record Toolkit, which showed improvement in administration rates. Such a toolkit has the potential to identify patients appropriately and avoid missed anti-D immune globulin prophylaxis events. © 2021 The Authors 
650 0 4 |a anti-D immunoglobulin 
650 0 4 |a electronic health record toolkit 
650 0 4 |a maternal-fetal alloimmunization 
650 0 4 |a missed prophylaxis 
650 0 4 |a never event 
650 0 4 |a obstetrical informatics 
650 0 4 |a obstetrical quality improvement 
650 0 4 |a rhesus immunoglobulin prophylaxis 
700 1 0 |a Babb, R.  |e author 
700 1 0 |a Bar-Shain, D.  |e author 
700 1 0 |a Brackney, K.  |e author 
700 1 0 |a Gibson, K.S.  |e author 
700 1 0 |a Hersh, A.  |e author 
700 1 0 |a Labbad, G.  |e author 
700 1 0 |a Rincon, M.  |e author 
773 |t AJOG Global Reports 
856 |z View Fulltext in Publisher  |u https://doi.org/10.1016/j.xagr.2021.100038