Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care.

Melissa E Bauer; Catherine Albright; Malavika Prabhu; R. Phillips Heine; Chelsea Lennox; Christie Allen; Carol Burke; April Chavez; Brenna L Hughes; Susan Kendig; Maile Le Boeuf; Elliott K. Main; Tiffany Messerall; Luis D Pacheco; Laura Riley; Rachel Solnick; Andrew Youmans; Ronald Gibbs

Organizational Policy/Guidelines

Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care.

October 11, 2023

Bauer ME, Albright C, Prabhu M, et al. Obstet Gynecol. 2023;142(3):481-492.

View more articles from the same authors.

Reducing maternal morbidity and mortality is a critical patient safety priority. Developed by the Alliance for Innovation on Maternal Health (AIM), this patient safety bundle provides guidance for healthcare teams to improve the prevention, recognition, and treatment of infections and sepsis among pregnant and postpartum patients.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Changes in medical errors after implementation of a handoff program.

November 12, 2014

Families as partners in hospital error and adverse event surveillance.

March 8, 2017

Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016

March 3, 2017

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020.

September 23, 2020

Exposures to structural racism and racial discrimination among pregnant and early post-partum Black women living in Oakland, California.

January 23, 2020

Effects on resident work hours, sleep duration and work experience in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS).

June 26, 2019

Extended work shifts and neurobehavioral performance in resident-physicians.

March 10, 2021

Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety.

July 19, 2023

Types, prevalence, and potential clinical significance of medication administration errors in assisted living.

June 4, 2008

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.

November 16, 2022

From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system.

March 1, 2017

An integrative total worker health framework for keeping workers safe and healthy during the COVID-19 pandemic.

July 1, 2020

Creating a high-reliability health care system: improving performance on core processes of care at Johns Hopkins Medicine.

January 21, 2015

Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial.

April 29, 2009

Caring for our own: deploying a systemwide second victim rapid response team.

April 28, 2010

Development of an emergency department trigger tool using a systematic search and modified Delphi process.

July 13, 2016

Prevalence and causes of diagnostic errors in hospitalized patients under investigation for COVID-19.

April 12, 2023

Thematic analysis of nurses' experiences with The Joint Commission's medication management titration standards.

September 15, 2021

Identifying and classifying diagnostic errors in acute care across hospitals: early lessons from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study.

February 21, 2024

Cardiac surgery errors: results from the UK National Reporting and Learning System.

February 16, 2011

Poor resident–attending intraoperative communication may compromise patient safety.

June 15, 2011

Significant reduction in preanalytical errors for nonphlebotomy blood draws after implementation of a novel integrated specimen collection module.

December 14, 2016

There's no place like home--integrating a pharmacist into the hospital-in-home model.

March 17, 2021

Association of patient and family reports of hospital safety climate with language proficiency in the US.

June 29, 2022

Classifying and predicting errors of inpatient medication reconciliation.

July 9, 2008

Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.

March 30, 2011

Balancing safety, comfort, and fall risk: an intervention to limit opioid and benzodiazepine prescriptions for geriatric patients.

January 11, 2023

Association of clinical specialty with symptoms of burnout and career choice regret among US resident physicians.

September 26, 2018

Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study.

December 19, 2018

Assessing the potential adoption and usefulness of concurrent, action-oriented, electronic adverse drug event triggers designed for the outpatient setting.

June 24, 2015

The HOSPITAL score predicts potentially preventable 30-day readmissions in conditions targeted by the Hospital Readmissions Reduction Program.

June 14, 2017

Multistate point-prevalence survey of health care-associated infections.

April 9, 2014

Improving care transitions: current practice and future opportunities for pharmacists.

December 5, 2012

Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based study.

July 22, 2020

Maternal and neonatal health care worker well-being and patient safety climate amid the COVID-19 pandemic.

March 31, 2021

Improving maternal safety at scale with the mentor model of collaborative improvement.

May 23, 2018

Hospital ward adaptation during the COVID-19 pandemic: a national survey of academic medical centers.

September 23, 2020

Improving allergy documentation: a retrospective electronic health record system-wide patient safety initiative.

January 1, 2022

Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient order errors: a randomized clinical trial.

May 29, 2019

Crowding in the Emergency Department: Challenges for the Care of Children.

March 15, 2023

Cumulative effect of flexible duty-hour policies on resident outcomes: long-term follow-up results from the FIRST trial.

July 15, 2020

Effect on patient safety of a resident physician schedule without 24-hour shifts.

July 15, 2020

Preventing home medication administration errors.

March 14, 2022

A comparison of error rates between intravenous push methods: a prospective, multisite, observational study.

November 1, 2017

Effect of bar-code technology on the safety of medication administration.

May 12, 2010

Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative.

May 18, 2022

Eradicating central line–associated bloodstream infections statewide: the Hawaii experience.

November 16, 2011

The Lancet Commission on lessons for the future from the COVID-19 pandemic.

October 12, 2022

Effect of a pediatric early warning system on all-cause mortality in hospitalized pediatric patients.

March 7, 2018

Improving discharge safety in a pediatric emergency department.

October 26, 2022

Decreasing handoff-related care failures in children's hospitals.

August 13, 2014

Potential role of pharmacogenomics in reducing adverse drug reactions: a systematic review.

August 31, 2005

Evaluation of wound photography for remote postoperative assessment of surgical site infections.

November 7, 2018

COVID-19: the dark side and the sunny side for patient safety.

October 14, 2020

Operational failures detected by frontline acute care nurses.

March 29, 2017

Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections.

August 25, 2010

Scaling-up a pharmacist-led information technology intervention (PINCER) to reduce hazardous prescribing in general practices: multiple interrupted time series study.

January 11, 2023

Evaluation of clinical practice guidelines on fall prevention and management for older adults: a systematic review.

January 12, 2022

Prospective validation of classification of intraoperative adverse events (ClassIntra): international, multicentre cohort study.

October 7, 2020

A preliminary taxonomy of medical errors in family practice.

March 6, 2005

Reevaluation of diagnosis in adults with physician-diagnosed asthma.

February 1, 2017

Applying trigger tools to detect adverse events associated with outpatient surgery.

March 16, 2011

Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology.

October 26, 2011

Partnered pharmacist charting on admission in the general medical and emergency short-stay unit—a cluster-randomised controlled trial in patients with complex medication regimens.

August 17, 2016

Taking patients' narratives about clinicians from anecdote to science.

August 19, 2015

Americans' growing exposure to clinician quality information: insights and implications.

March 20, 2019

What words convey: the potential for patient narratives to inform quality improvement.

April 24, 2019

Use of cascading A3s to drive systemwide improvement.

August 2, 2017

A method to identify pediatric high-risk diagnoses missed in the emergency department.

August 8, 2018

National survey of patient safety experiences in hospital medicine during the COVID-19 pandemic.

January 10, 2024

Testing process errors and their harms and consequences reported from family medicine practices: a study of the American Academy of Family Physicians National Research Network.

June 11, 2008

Ambulatory prescribing errors among community-based providers in two states.

December 21, 2011

Comparative performance of pediatric weight estimation techniques: a human factor errors analysis.

November 1, 2017

In their own words: safety and quality perspectives from families of hospitalized children with medical complexity.

September 6, 2023

National cluster-randomized trial of duty-hour flexibility in surgical training.

February 10, 2016

Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial.

January 17, 2007

Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017.

May 10, 2017

American College of Surgeons' Committee on Trauma performance improvement and patient safety program: maximal impact in a mature trauma center.

December 14, 2011

Evolving quality improvement support strategies to improve Plan–Do–Study–Act cycle fidelity: a retrospective mixed-methods study.

May 1, 2019

The MedSafer study-electronic decision support for deprescribing in hospitalized older adults: a cluster randomized clinical trial.

February 2, 2022

I-PASS, a mnemonic to standardize verbal handoffs.

April 11, 2012

Effect of work-hours regulations on intensive care unit mortality in United States teaching hospitals.

September 2, 2009

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

August 4, 2021

Pediatric antidepressant medication errors in a national error reporting database.

February 17, 2010

Characteristics of pediatric chemotherapy medication errors in a national error reporting database.

June 13, 2007

Medication errors in the ambulatory treatment of pediatric attention deficit hyperactivity disorder.

September 3, 2008

Prescription opioid dose reductions and potential adverse events: a multi-site observational cohort study in diverse US health systems.

November 29, 2023

Follow-up of abnormal screening mammograms among low-income ethnically diverse women: findings from a qualitative study.

December 8, 2008

Reducing pediatric emergency department prescription errors.

June 22, 2022

Description and evaluation of an interprofessional patient safety course for health professions and related sciences students.

January 10, 2007

Medication errors in pediatric anesthesia: a report from the Wake Up Safe quality improvement initiative.

November 22, 2017

Optimization of drug–drug interaction alert rules in a pediatric hospital's electronic health record system using a visual analytics dashboard.

December 10, 2014

I-PSI: short- and long-term efficacy of a comprehensive initiative to promote patient safety event reporting by trainees.

August 25, 2021

ASHP–PPAG Guidelines for Providing Pediatric Pharmacy Services in Hospitals and Health Systems.

August 8, 2018

Using the WHO International Classification of patient safety framework to identify incident characteristics and contributing factors for medical or surgical complication deaths

October 2, 2019

A randomized trial of a multifactorial strategy to prevent serious fall injuries.

July 29, 2020

Adverse drug event rates in six community hospitals and the potential impact of computerized physician order entry for prevention.

November 25, 2009

Return on investment for vendor computerized physician order entry in four community hospitals: the importance of decision support.

July 10, 2013

No interruptions please: impact of a no interruption zone on medication safety in intensive care units.

January 27, 2010

Related Resources

WebM&M Cases

Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy

March 27, 2024

Communication and birth experiences among Black birthing people who experienced preterm birth.

February 14, 2024

The intersection of traumatic childbirth and obstetric racism: a qualitative study.

February 7, 2024

A combined assessment tool of teamwork, communication, and workload in hospital procedural units.

January 17, 2024

Factors influencing second victim experiences and support needs of OB/GYN and pediatric healthcare professionals after adverse patient events.

January 17, 2024

Respectful Maternity Care: Dissemination and Implementation of Perinatal Safety Culture to Improve Equitable Maternal Healthcare Delivery and Outcomes.

January 10, 2024

Using Change Packages to Support AIM Bundle Implementation.

January 10, 2023 - April 10, 2023

'Nobody cared': Women who have reported mistreatment while giving birth say CDC report validates their trauma. Advocates call for systemic change in treatment of pregnant people.

December 6, 2023

Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief.

November 15, 2023

Hiding in plain sight: inconvenient facts for patient safety in non-24/7 theatre on-site staffed obstetric units.

September 6, 2023

When the lights go down in the delivery room: lessons from a ransomware attack.

September 6, 2023

WebM&M Cases

Prolonged DKA in Pregnancy: A Case of Communication Breakdown.

August 30, 2023

Quality and safety practices among academic obstetrics and gynecology departments.

August 30, 2023

Toolkits To Reduce Hypertension in Pregnancy and Obstetric Hemorrhage.

August 16, 2023

Amid lack of accountability for bias in maternity care, a California family seeks justice.

August 16, 2023

Advancing Diagnostic Excellence in Maternal Health Care.

July 27, 2023 - July 27, 2023

Causes for medical errors in obstetrics and gynaecology.

June 28, 2023

A call for safety: anticipating and mitigating risk across an obstetrics and gynecology service line.

June 21, 2023

Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs Decision.

June 7, 2023

Why do so many Black women die in pregnancy? One reason: doctors don't take them seriously.

May 31, 2023

Psychosocial processes in healthcare workers: how individuals' perceptions of interpersonal communication is related to patient safety threats and higher-quality care.

May 31, 2023

Racial and ethnic disparities in obstetric and gynecologic care and role of implicit biases.

May 18, 2023

The time is now: addressing implicit bias in obstetrics and gynecology education.

May 17, 2023

Listen to the whispers before they become screams: addressing Black maternal morbidity and mortality in the United States.

May 3, 2023

Saving Moms.

April 19, 2023

Addressing Medical Gaslighting to Improve Maternal Health—Together.

March 29, 2023

Journal Article

Study

Pilot implementation of a health equity checklist to improve the identification of equity-related adverse events.

March 29, 2023

Society for Maternal-Fetal Medicine Special Statement: curriculum outline on patient safety and quality for maternal-fetal medicine fellows.

March 22, 2023

Reducing preventable adverse events in obstetrics by improving interprofessional communication skills--results of an intervention study.

March 1, 2023

Maternal and Infant Health Inequality: New Evidence from Linked Administrative Data.

February 22, 2023

See More About The Topic

Hospitals

Labor and Delivery

Ambulatory Clinic or Office

Gynecology

Obstetrics

Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care.

Pilot implementation of a health equity checklist to improve the identification of equity-related adverse events.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care.

Pilot implementation of a health equity checklist to improve the identification of equity-related adverse events.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site