Healthcare Facility Compliance 11 items
Obstetrics & Labor and Delivery Safety Audit
Maternal safety audit covering obstetric hemorrhage readiness, hypertension/preeclampsia management, high-alert medications, and fetal monitoring on labor and delivery units.
CMS 42 CFR 482.60AWHONN StandardsACOG GuidelinesTJC PC.06.01.03
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Maternal Hemorrhage Readiness
- Is an obstetric hemorrhage cart or kit with uterotonics and supplies immediately available on the unit? *
- Is quantitative blood loss (QBL) measured rather than estimated for all births? *
- Is a stage-based obstetric hemorrhage protocol with a massive transfusion pathway in place? *
Hypertension & Preeclampsia
- Is severe-range hypertension (>=160/110) treated with first-line antihypertensives within 60 minutes? *
- Is magnesium sulfate available and used for seizure prophylaxis in preeclampsia with severe features? *
- Are staff educated on recognition of preeclampsia warning signs and early warning criteria? *
High-Alert Medication Safety
- Is oxytocin managed as a high-alert medication with standardized concentrations and checklists? *
- Is magnesium sulfate administered via smart pump with independent double checks? *
Fetal Monitoring & Emergency Response
- Do clinicians use standardized NICHD fetal heart rate terminology for interpretation and documentation? *
- Are emergency drills for shoulder dystocia, hemorrhage, and eclampsia conducted and debriefed regularly? *
- Is a plan for emergency cesarean (decision-to-incision) capability maintained and tested? *
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