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Maternal Safety

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    • Last Updated: December 23, 2022
    Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team
    Description
    Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, collaborative initiatives, teamwork, and trigger tools.
    Library Organization
    Custom - This library is organized by custom section header names.
    Foundations (6)
    Maternal Safety

    Pregnancy, childbirth, and the postpartum year present a complex set of patient safety challenges. Numerous maternal safety initiatives aim to prevent errors and harm, while enhancing readiness to address maternal complications.

    Maternal Safety
    Audrey Lyndon, RN, PhD |

    This perspective examines the troubling decline in maternal health outcomes in the United States and summarizes recent national initiatives to improve safety in maternity care.

    Perinatal high reliability.
    Knox E, Simpson KR. Am J Obstet Gynecol. 2011;204:373-377.

    This review provides background on high-reliability organizations and discusses how these concepts are applied in obstetric care.

    Alliance for Innovation on Maternal Health.
    American College of Obstetricians and Gynecologists.

    This website provides information from a multidisciplinary collaboration whose mission was to support safe health care for pregnant and post partum people. The site, maintained by the American College... Read More

    Toolkit for Improving Perinatal Safety.
    Rockville, MD: Agency for Healthcare Research and Quality. June 2017.

    Communication in labor and delivery units can be challenging. This AHRQ-funded program draws from comprehensive unit-based safety program principles to reduce errors in maternal and neonatal care. The toolkit... Read More

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    Improving Diagnosis and Treatment of Maternal Sepsis.

    Stanford, CA; California Maternal Quality Care Collaborative: July 1, 2022. 

    This toolkit focuses on identification of, and rapid response to, sepsis in obstetric patients. It includes screening, evaluation and monitoring, and antibiotic use recommendations for maternal... Read More

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    HEAR Her Concerns.

    National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health; Centers for Disease Control and Prevention. 

    Maternal harm during and after pregnancy is a sentinel event. This campaign encourages women, families, and health providers to identify and speak up with concerns about maternal care and act on them. The program seeks to inform the... Read More

    Team training for safer birth.
    Cornthwaite K, Alvarez M, Siassakos D. Best Pract Res Clin Obstet Gynaecol. 2015;29:1044-1057.

    Obstetric care is considered a high-risk environment. Highlighting the importance of coordinated teamwork during obstetric emergencies, this review discusses strategies to augment clinical outcomes in this setting,... Read More

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    All Library Content (23)
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    Study
    Distinguishing high-performing from low-performing hospitals for severe maternal morbidity: a focus on quality and equity.
    Howell EA, Sofaer S, Balbierz A, et al. Obstet Gynecol. 2022;139:1061-1069.
    Health equity in maternal safety is a major patient safety goal. Researchers interviewed health care professionals, including frontline nurses and physicians, chief medical officers, and quality and safety officers, from high- and low-performing hospitals. Six themes emerged differentiating high and low performers: 1) senior leadership involved in day-to-day quality activities and dedicated to quality improvement, 2) a strong focus on standards and standardized care, 3) strong nurse-physician communication and teamwork, 4) adequate physician and nurse staffing and supervision, 5) sharing of performance data with nurses and other frontline clinicians, and 6) explicit awareness that racial and ethnic disparities exist and that racism and bias in the hospital can lead to differential treatment. PSNet offers a Patient Safety Primer and Curated Library on maternal safety.
    Study
    Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity.
    Davidson C, Denning S, Thorp K, et al. BMJ Qual Saf. 2022;31:670-678.
    People of color experience disproportionately higher rates of maternal morbidity and mortality. As part of a larger quality improvement and patient safety initiative to reduce severe maternal morbidity from hemorrhage (SMM-H), this hospital analyzed administrative data stratified by race and ethnicity, and noted a disparity between White and Black patients. Review of this data was integrated with the overall improvement bundle. Post-implementation results show that SMM-H rates for Black patients decreased.
    Multi-use Website
    HEAR Her Concerns.

    National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health; Centers for Disease Control and Prevention. 

    Maternal harm during and after pregnancy is a sentinel event. This campaign encourages women, families, and health providers to identify and speak up with concerns about maternal care and act on them. The program seeks to inform the design of support systems and tool development that enhance maternal safety.
    Organizational Policy/Guidelines
    National Partnership for Maternal Safety: consensus bundle on support after a severe maternal event.
    Morton CH, Hall MF, Shaefer SJM, et al. J Obstet Gynecol Neonatal Nurs. 2021;50:88-101.
    Individuals involved in adverse maternal events require support both physically and emotionally. This guidance combines readiness, recognition, response, and reporting and systems-learning steps to aid birthing facility nurses and management in providing standardized help for mothers, families, and care team members that experience care-related harm.  
    Toolkit
    Improving Diagnosis and Treatment of Maternal Sepsis.

    Stanford, CA; California Maternal Quality Care Collaborative: July 1, 2022. 

    This toolkit focuses on identification of, and rapid response to, sepsis in obstetric patients. It includes screening, evaluation and monitoring, and antibiotic use recommendations for maternal sepsis patient.
    Book/Report
    Providing Safe, High-Quality Maternity Care in Rural US Hospitals. IHI Innovation Report.

    Laderman M, Renton M. Boston, MA: Institute for Healthcare Improvement; 2020.

    Maternal care safety is challenged by operational, public health and individual provider limitations. The report outlines specific areas of concern for rural hospitals and suggests avenues for improvement. Strategies suggested using simulation to prepare staff and training on implicit bias.
    Maternal Safety
    Audrey Lyndon, RN, PhD |
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    • This perspective examines the troubling decline in maternal health outcomes in the United States and summarizes recent national initiatives to improve safety in maternity care.
    Commentary
    Emerging Classic
    Delivering high reliability in maternity care: in situ simulation as a source of organisational resilience.
    Macrae C, Draycott T. Safety Sci. 2019;117:490-500.
    Simulation training can enhance teamwork, identify latent problems, and contribute to improved patient outcomes. This commentary explores the value of frontline obstetric simulation to develop high reliability. The authors discuss relational rehearsal, system structuring, and practice elaboration as elements of a successful simulation-focused organizational learning initiative.
    Maternal Safety
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    • Pregnancy, childbirth, and the postpartum year present a complex set of patient safety challenges. Numerous maternal safety initiatives aim to prevent errors and harm, while enhancing readiness to address maternal complications.
    Study
    A multidisciplinary model for reviewing severe maternal morbidity cases and teaching residents patient safety principles.
    Ogunyemi D, Hage N, Kim SK, et al. Jt Comm J Qual Patient Saf. 2019;45:423-430.
    The rise in maternal morbidity and mortality is one of the most pressing patient safety issues in the United States. Formal debriefing after adverse events is an important method for analyzing and improving safety. In this study, an academic hospital adopted a systems-based morbidity and mortality conference model to review cases of serious maternal harm and implemented several safety measures (including teamwork training) to address issues that were identified through structured review.
    Study
    The impact of patient–physician alliance on trust following an adverse event.
    Shoemaker K, Smith CP. Patient Educ Couns. 2019;102:1342-1349.
    Maternal morbidity has garnered increasing attention as a patient safety issue. This survey of postpartum women elicited reports of adverse events, unanticipated procedures, and sense of betrayal in health care institutions. Patients' reports of adverse events were associated with lack of trust in physicians. Investigators found that patients who reported more engagement in decision-making maintained more trust in physicians than less engaged patients. The authors suggest that shared decision-making may mitigate some of the loss of trust associated with adverse events. A recent Annual Perspective summarized national initiatives to improve safety in maternity care.
    Study
    Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care.
    Kahwati LC, Sorensen A, Teixeira-Poit S, et al. Jt Comm J Qual Patient Saf. 2019;45:231-240.
    Labor and delivery is an inherently high-risk care setting. The Agency for Healthcare Research and Quality adapted its Comprehensive Unit-based Safety Program, a best practice toolkit incorporating teamwork, human factors engineering principles, and simulation training, for labor and delivery. In this pre–post evaluation study, staff reported improved safety culture and teamwork. Obstetric trauma and primary cesarean delivery rates declined after the intervention, but neonatal birth trauma rates increased. The authors note that incomplete implementation and lack of sustained program participation observed in the study should be addressed in order to improve obstetric and neonatal care safety. A recent Annual Perspective emphasizes the rising rate of severe maternal morbidity and summarizes national initiatives to improve safety in maternity care.
    Study
    Integrated approach to reduce perinatal adverse events: standardized processes, interdisciplinary teamwork training, and performance feedback.
    Riley W, Begun JW, Meredith L, et al. Health Serv Res. 2016;51:2431-2452.
    Prior research has shown that reducing preventable perinatal harm leads to a decrease in malpractice claims. In this prospective study involving the perinatal units across 14 hospitals from 12 states and accounting for almost 350,000 deliveries, researchers found that successful implementation of 3 standard care processes resulted in a 14% decrease in harm in perinatal care from the baseline period.
    Study
    Thematic analysis of women's perspectives on the meaning of safety during hospital-based birth.
    Lyndon A, Malana J, Hedli LC, et al. J Obstet Gynecol Neonatal Nurs. 2018;47:324-332.
    A vital component of engaging patients in safety is eliciting their perspective on how they experience both routine care and adverse events. Researchers interviewed women who gave birth in hospitals about what contributed to their sense of safety. Participants emphasized clear communication and empathy as strategies to avoid psychological harm.
    Study
    Improving maternal safety at scale with the mentor model of collaborative improvement.
    Main EK, Dhurjati R, Cape V, et al. Jt Comm J Qual Patient Saf. 2018;44:250-259.
    This study describes the implementation of a quality improvement initiative for obstetric safety across California. Instead of a traditional statewide collaborative, this program divided participating health systems into groups of six to eight hospitals, led by a physician and nurse dyad as mentors. Participants reported that this mentored approach functioned better than the larger quality improvement collaborative model.
    Multi-use Website
    Alliance for Innovation on Maternal Health.
    American College of Obstetricians and Gynecologists.
    This website provides information from a multidisciplinary collaboration whose mission was to support safe health care for pregnant and post partum people. The site, maintained by the American College of Obstetricians and Gynecologists, includes collections of patient safety bundles, tools to facilitate review of maternal morbidity, a toolkit for implementing safety initiatives, and educational presentations focused on improving the safety of women's health care. The initiative was named Council on Patient Safety in Women's Health Care until August 2021.
    Toolkit
    Toolkit for Improving Perinatal Safety.
    Rockville, MD: Agency for Healthcare Research and Quality. June 2017.
    Communication in labor and delivery units can be challenging. This AHRQ-funded program draws from comprehensive unit-based safety program principles to reduce errors in maternal and neonatal care. The toolkit provides guidance and materials focused on enhancing teamwork skills, implementing perinatal safety strategies, and utilizing in situ simulation. Team training modules and care bundles are shared to enable skill development. A previous WebM&M commentary explored a near miss with a neonate.
    Study
    Impact of a comprehensive patient safety strategy on obstetric adverse events.
    Pettker CM, Thung SF, Norwitz ER, et al. Am J Obstet Gynecol. 2009;200:492.e1-8.
    A multifaceted approach to patient safety resulted in improvements in both patient- and provider-related outcomes over a 3-year time frame. The strategy was developed after consultation with obstetric safety experts and included teamwork training, standardization of care protocols, and establishment of a robust quality assurance mechanism (including a dedicated patient safety nurse). Progressive implementation of the safety interventions was associated with a steady reduction in maternal and fetal adverse events, as well as improvement in the overall perception of safety culture (as measured by the Safety Attitudes Questionnaire). Prior research has demonstrated the effectiveness of crew resource management training in improving obstetric safety.
    Study
    Use of maternal early warning trigger tool reduces maternal morbidity.
    Shields LE, Wiesner S, Klein C, et al. Am J Obstet Gynecol. 2016;214:527.e1-527.e6.
    Many organizations, including The Joint Commission and the National Partnership for Maternal Safety, recommend the use of early warning systems when treating maternity patients. This prospective study evaluated a maternal early warning trigger tool that was internally developed and piloted at six hospitals within a large health system. The tool was pathway specific and targeted the four most common causes of maternal morbidity: hemorrhage, preeclampsia, sepsis, and cardiac dysfunction. Severe maternal morbidity, as defined by the Centers for Disease Control and Prevention, and composite morbidity significantly decreased following implementation of this tool compared with both baseline rates and control hospitals. In 2010, The Joint Commission issued a sentinel event alert on preventing maternal death.
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