Using the SEIPS Model to Assess a Maternal Hemorrhage Risk Alert Tool

Deaths resulting from maternal hemorrhage (MH), for example, excessive blood loss related to childbirth, are preventable if the hemorrhage is identified in a timely manner. One approach to support timely identification is the use of alerts. However, alerts with low utility have negative, unanticipated consequences for both clinician and patient outcomes. This study has two objectives: (1) use the Systems Engineering Initiative for Patient Safety model to describe how the MH risk alert tool is used in the care process, and (2) evaluate the utility of the MH risk alert tool from the perspective of the care team. We performed observations to understand the care process and fielded a survey to evaluate the alarm utility. Our results showed that the MH risk alert tool is used throughout the care process, both antepartum and postpartum. Additionally, our results showed that workflow integration, usefulness, and trustworthiness of the alert need to be improved.