2013 MOREOB Patient Safety Award Winner

Hospital: Bellin Health, Kress Birthing Center
City: Green Bay, Wisconsin
Initiative: Postpartum Hemorrhage Skills Drill and Emergency Cart


The Kress Birthing Center continues on in their MOREOB journey. The priority of keeping our patients safe is our driving force!

During Staff Education Day post partum hemorrhage (PPH) drill, our staff experienced what we felt were unnecessary delays in obtaining uterotonic medications. As a result of asking "how can we do this better?" PPH was chosen as a Module II workshop presentation and became a featured Skills Drill for the Module II Workshop.

The MOREOB Core Team and our staff Operations Council worked collaboratively to create a tool kit comprised of:

  1. An Emergency Cart
  2. A Hemorrhage Medication Kit
  3. PPH Drill Scenario
  4. Acronym for PPH interventions
    • ATONOR
      • Assess (Circulation, Airway, Breathing)
      • Team (call for help)
      • Output (place a Foley
      • Need (for medication)
      • Operating Room (plan for)


Reacting quickly to a PPH is vital. For this reason, MOREOB Core Team members and OBGYN physicians created a PPH drill scenario and the ATONOR acronym to enhance the Maternity Team's learning and effectiveness during an actual emergency.

An Emergency Cart was created to establish a "one stop shop" for all supplies required in a PPH.

The cart allows for efficient and rapid access to items needed for a PPH. The cart is kept in a centrally located equipment room. The cart contains:

  • PPH Decision Tree
  • Medication list—first round treatment and then 2nd round treatment with doses. routes, contraindications and how often utertonics can be repeated
  • IV fluids for bolus
  • Hypodermic needles
  • IV start kit
  • IV tubing
  • Laminated sheet noting average weight of peripads and chux
  • Chux
  • Scale
  • Indwelling Foley catheter

We utilize a medication dispensing system called a Pyxis machine. While we were able to override uterotonic medications, the design of Pyxis required an untimely pause to address questions before allowing access to the medication. When two medications were needed, each one had to be searched out separately. In considering a leaner process, Pharmacy and the Core Team created a Hemorrhage Medication Kit. Access to the kit allows staff to readily select emergent medications (20 u Pitocin in LR, Hemabate, Methergine, and/or Cytotec) in a streamlined manner. Medications may be taken out separately or all at one time. Part of the access re-design included removal of questions that are required when taking the medications out separately which was seen as a barrier in obtaining emergency related medications. The Hemorrhage Medication Kit will increase our response time when treating a woman experiencing a PPH.

Additional process improvements are in the planning phase. The Maternity Unit is working with Pharmacy, Biomed, and EPIC analysts to replace our current 20units of Pitocin in 1000mL of LR with 30units of Pitocin in 500mL of LR. This will allow for the staff to quickly access a higher dose of Pitocin during a PPH without waiting for Pharmacy to remotely mix and deliver the higher concentration to our department. This will be implemented early in 2014.

The PPH Skills Drill, ATONOR acronym, Emergency Cart, and Hemorrhage Medication Kit was introduced to physicians, midlevel providers, labor nurses, postpartum nurses, nursery nurses, surgical techs and unit assistants (CNA's) at the Module II Workshops in November and December, 2013. The Emergency Cart and Hemorrhage Medication Kit were rolled out on December 3, 2013. The implementation of these safety features will increase our response effectiveness to postpartum hemorrhages.


Staff members continue to assess, modify and evaluate how to improve current practice and implement processes that will improve the safety of our patients Implementation of the Emergency Cart and Hemorrhage Medication Kit will increase our response and effectiveness to postpartum hemorrhages. Utilizing the ATONOR acronym, Emergency Cart and Hemorrhage Medication kit during our PPH drills will solidify the use of these tools in real life patient situations. Ultimately our patients will benefit from this process change.

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Au-delà de l’obstétrique

Nous pouvons appliquer une démarche similaire à celle que nous suivons en obstétrique sur le plan de la communication et du travail d’équipe aux services connexes de maternité et de soins aux nouveau-nés et même aux autres unités hospitalières comme les soins d’urgence, les soins intensifs, la cardiologie et les autres services spécialisés dans la gestion des risques.