News release: National

April 18 , 2005

For more information, call:
Laura H. Marshall
National Communications
Kaiser Permanente
Phone: (510) 271-5953

Kaiser Permanente Hosts Conference Focused on Perinatal Patient Safety

Harvard School of Public Health, Johns Hopkins Quality and Safety Research Group, Stanford University send featured speakers

San Francisco , CA— Focusing on the safe and healthy birth of children borne by higher-risk mothers, Kaiser Permanente will host a patient safety conference April 21 st and 22 nd in San Francisco intended to share best practices among other health experts.

Michael Leonard, MD, a nationally known speaker on patient safety programs, will address “The Next Generation” of human factors that need to be addressed on the first day of the conference.
Steve Howard, MD, Associate Director of Patient Safety at the VA’s Palo Alto Health Care System and an Associate Professor at Stanford University , will speak on Fatigue Management on day two.
Michelle M. Mello, J.D., Ph.D., Assistant Professor of Health Policy and Law at the Harvard School of Public Health, will show how health care organizations learn from legal issues when she presents insights from the Malpractice Insurers Medical Error Prevention Study.

Kaiser Permanente’s patient safety work can be traced to the health plan’s beginnings as a preventive care plan for shipyard and construction workers, and includes the involvement of former Health Plan President and CEO Dr. David Lawrence in the Institute of Medicine ’s groundbreaking study, “To Err is Human.”

Perinatal patient safety focuses on the hours around birth, ensuring that the team of clinical professionals caring for an expectant mother is prepared to act cohesively and decisively together in the case of an emergency. One mother says she knew something had changed during the birth of her child when her team of Kaiser Permanente physicians and nurses immediately coalesced and began focusing on her child in a coordinated, urgent way that had clearly been practiced and perfected.

The training Kaiser Permanente clinicians go through includes using high-tech robotic humans—mother, father, and child—to simulate emergencies. The robots are programmed to generate simulated crisis situations, and humans provide voices that mimic the agitation and confusion felt by family during a birth emergency. Paul Preston, MD, physician in charge of KP’s PPS training, says “the training can feel very real to the doctors and nurses going through it. That experience means Kaiser Permanente birthing teams can learn how to react with calm and precision in emergencies without having to learn on real people.”

A key part of patient safety training at KP is a technique adapted from the [U.S. Navy] called “SBAR” training; SBAR stands for Situation, Background, Assessment, Recommendation and is a model for communication in emergencies that can prevent misunderstanding between members of a team. Dr. Leonard will address SBAR training on the first day of the conference.

Kaiser Permanente is America’s leading integrated health plan. Founded in 1945, it is a not-for-profit, group practice prepayment program with headquarters in Oakland, California . Kaiser Permanente serves the health care needs of 8.2 million members in 9 states and the District of Columbia . Today it encompasses the not-for-profit Kaiser Foundation Health Plan, Inc., Kaiser Foundation Hospitals and their subsidiaries, and the for-profit Permanente Medical Groups.

Nationwide, Kaiser Permanente includes approximately 138,000 technical, administrative and clerical employees and caregivers, and more than 11,000 physicians representing all specialties.