Eliminating racial and ethnic disparities causing mortality and morbidity in pregnant and postpartum patients.

Sentinel Event Alerts

Eliminating racial and ethnic disparities causing mortality and morbidity in pregnant and postpartum patients.

January 25, 2023

Sentinel Event Alert. January 17, 2023:(66):1-5.

Racial and ethnic inequalities are emerging as a primary contributor to harmful maternal care. This guidance examines obstacles to safe care for mothers of color and shares recommendations to reduce disparities such as team-based care and implicit bias training.

Information

Free full text (PDF)

Related report (PDF)

Related Resources From the Same Author(s)

Preventing unintended retained foreign objects.

October 23, 2013

ADC survey shows some improvements, but unnecessary risks still exist.

February 6, 2008

Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.

January 23, 2019

Health care workers in the midst of crisis.

February 10, 2021

Diagnostic overshadowing among groups experiencing health disparities.

June 29, 2022

Managing the risks of direct oral anticoagulants.

August 7, 2019

Addressing health care disparities by improving quality and safety.

November 24, 2021

Managing risk during transition to new ISO tubing connector standards.

August 27, 2014

Medical device alarm safety in hospitals.

April 10, 2013

Preventing falls and fall-related injuries in health care facilities.

October 7, 2015

Safe use of health information technology.

April 8, 2015

Leadership committed to safety.

September 2, 2009

Safely implementing health information and converging technologies.

January 7, 2009

World Patient Safety Day.

March 6, 2023

Inadequate hand-off communication.

September 20, 2017

Radiation risks of diagnostic imaging and fluoroscopy.

August 31, 2011

Physical and verbal violence against health care workers.

June 18, 2021

Health care worker fatigue and patient safety.

January 30, 2005

Just Culture and its critical link to patient safety—part 1 and part 2.

July 25, 2012

ISMP 2007 survey on high-alert medications. Differences between nursing and pharmacy perspectives still prevalent.

May 30, 2007

Mail service and community pharmacies must work in tandem.

November 30, 2005

Is an indication-based prescribing system in our future?

November 30, 2016

With oral chemotherapy, we simply must do better!

July 30, 2014

Heparin errors continue despite prior, high-profile, fatal events.

August 6, 2008

Preventing errors when preparing and administering medications via enteral feeding tubes.

December 7, 2022

Maalox Total Relief and Maalox Liquid Products: Medication Use Errors.

March 3, 2010

Latent and active failures perfectly align to allow a preventable adverse event to reach a patient.

February 1, 2023

ISMP updates its list of drug names with tall man (mixed case) letters based on survey results.

February 8, 2023

Unite for Safe Care.

September 17, 2021 - September 17, 2021

Advancing safety with closed-loop communication of test results.

January 15, 2020

Save a brain, make a checklist.

April 2, 2014

Why it's so easy for doctors to misdiagnose kids.

December 2, 2015

When the water breaks.

August 3, 2022

Your diagnosis was wrong. Could doctor bias have been a factor?

December 11, 2019

Health systems and hospitals in pursuit of high reliability.

May 1, 2019

How to prevent the top 4 medication errors.

October 17, 2018

Former pharmacist indicted for manslaughter after med error.

October 3, 2007

Rating hospitals by the stars: the feds' latest plan to measure quality is the most controversial.

June 1, 2016

Near-miss events detected using the emergency department trigger tool.

March 15, 2023

Health Worker Safety: A Priority for Patient Safety.

September 30, 2020

‘Fear of falling’: how hospitals do even more harm by keeping patients in bed.

November 6, 2019

Reducing adverse obstetrical outcomes through safety sciences.

November 27, 2022

The biggest mistake doctors make.

November 27, 2013

Drug shortages persist in US, harming care.

November 28, 2012

Computer viruses are "rampant" on medical devices in hospitals.

October 31, 2012

Inquiry into reporter's death finds multiple failures in care.

July 5, 2006

Irked by drug-interaction alerts? Customize them, experts advise.

April 26, 2006

For Colorado mom, story of daughter's hospital death is key to others' safety.

March 4, 2015

Most dangerous time at the hospital? It may be when you leave.

March 30, 2016

Medicare releases patient safety ratings for hospitals.

October 26, 2011

Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.

March 30, 2022

Healing the hospital hierarchy.

March 27, 2013

Hospital design plays important role in patient outcomes.

April 27, 2005

More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety.

July 30, 2014

Infections associated with reprocessed flexible bronchoscopes.

September 30, 2015

Transparency and public reporting are essential for a safe health care system.

April 7, 2010

Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020.

March 16, 2022

Doctors and dentists still flooding U.S. with opioid prescriptions.

July 29, 2020

Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died.

December 16, 2020

Mental health conditions leading cause of pregnancy-related deaths.

February 15, 2023

Home medical device safety tops ECRI'S list of healthcare technology.

February 15, 2023

Driving Learning and Improvement After RCA2 Event Reviews.

January 26, 2023 - January 26, 2023

Safer Together Survey: Advancing Patient and Workforce Safety

January 18, 2023

New AHRQ SOPS Workplace Safety Supplemental Item Set for Nursing Homes.

February 15, 2023

National Safety Standards for Invasive Procedures (NatSSIPs2).

February 7, 2023

Medical malpractice claims by members of the uniformed services.

July 7, 2021

A deadly epidural, delivered by a doctor with a history of mistakes.

February 1, 2023

Anesthesia outside of the OR: cause for patient safety concerns?

January 25, 2023

Bleeding and in pain, a pregnant woman in Louisiana couldn’t get answers.

January 25, 2023

During in-flight emergencies, sometimes airlines’ medical kits fall short.

January 18, 2023

Medication safety issues with newly authorized PAXLOVID.

January 12, 2022

The five rights: a destination without a map.

February 7, 2007

Double key bounce and double keying errors.

January 31, 2006

Start the year off right by preventing these top 10 medication errors and hazards from 2020.

February 10, 2021

Learning from errors with the new COVID-19 vaccines.

January 27, 2021

Start the new year off right by preventing these top 10 medication errors and hazards.

January 29, 2020

Start the year off right by addressing these top 10 medication safety concerns from 2021.

February 9, 2022

Drug shortages continue to compromise patient care.

January 24, 2018

Anticoagulant safety takes center stage in 2007.

January 24, 2007

Technology and error-prevention strategies: why are we still overlooking the IV room?

January 28, 2015

Survey shows recession has weakened patient safety net.

January 27, 2010

Guidelines for timely medication administration: response to the CMS "30-minute rule."

January 26, 2011

Nimodipine Capsules (marketed as Nimotop).

March 1, 2006

The Joint Commission and National Quality Forum Announce 2022 Eisenberg Award Recipients.

February 1, 2023

Meitheal Pharmaceuticals, Inc. issues voluntary nationwide recall of Cisatracurium Besylate Injection, USP 10mg per 5mL due to mislabeling.

February 10, 2021

FDA updates vinca alkaloid labeling for preparation in intravenous infusion bags only.

February 3, 2021

Medical abbreviations that have contradictory or ambiguous meanings.

February 12, 2020

Implantable infusion pumps in the magnetic resonance (MR) environment: FDA safety communication—important safety precautions.

January 25, 2017

FDA Drug Safety Communication: FDA requires labeling changes for prescription opioid cough and cold medicines to limit their use to adults 18 years and older.

February 7, 2018

Morphine sulfate oral solution 100 mg per 5 mL (20 mg/mL): medication use error—reports of accidental overdose.

January 19, 2011

Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing?

December 19, 2012

Reduce readmissions with pharmacy programs that focus on transitions from the hospital to the community.

November 28, 2012

Raising the index of suspicion: red flags that represent credible threats to patient safety.

August 8, 2012

Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors.

July 18, 2012

Sterile compounding tragedy is a symptom of a broken system on many levels.

October 31, 2012

Inappropriate use of pharmacy bulk packages of IV contrast media increases risk of infections.

October 3, 2012

Prescription drug time guarantees and their impact on patient safety in community pharmacies.

September 19, 2012

A shortage of everything except errors: harm associated with drug shortages.

May 2, 2012

Results of our survey on drug storage, stability, compatibility, and beyond use dating.

April 4, 2012

Good intention, uncertain outcome...our take on physician dispensing in offices and clinics.

March 21, 2012

Related Resources

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

November 15, 2023

Sentinel Event Alert 68: Updated surgical fire prevention for the 21st Century.

November 8, 2023

Vital signs: maternity care experiences — United States, April 2023.

September 6, 2023

Dangers and deaths around black pregnancies seen as a ‘completely preventable’ health crisis.

September 6, 2023

‘The Retrievals’ reveals painful experiences of female patients are often ignored.

September 6, 2023

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

September 6, 2023

Quality and safety practices among academic obstetrics and gynecology departments.

August 30, 2023

‘I felt like I was dying’: how women with postpartum depression fall through the cracks of U.S. health care.

July 5, 2023

Causes for medical errors in obstetrics and gynaecology.

June 28, 2023

After Roe: Challenges in the Provision of Lifesaving Care.

June 21, 2023

The Ohio Maternal Safety Quality Improvement Project: initial results of a statewide perinatal hypertension quality improvement initiative implemented during the COVID-19 pandemic.

June 7, 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

Three missed critical nursing care processes on labor and delivery units during the COVID-19 pandemic.

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

Racial bias in cesarean decision-making.

May 10, 2023

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

May 3, 2023

Doctors must stop tuning out Black women. It happened to me, as a pregnant OB-GYN.

April 26, 2023

Saving Moms.

April 19, 2023

Mothers face broken addiction treatment system.

April 12, 2023

Perspective

Maternal Safety and Perinatal Mental Health

March 29, 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

Interview

In Conversation with Christie Allen about Maternal Safety and Perinatal Mental Health

March 28, 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

Investigating the impact of structural racism on Black birthing people - associations between racialized economic segregation, incarceration inequality, and severe maternal morbidity.

February 15, 2023

Mental health conditions leading cause of pregnancy-related deaths.

February 15, 2023

Using potentially preventable severe maternal morbidity to monitor hospital performance.

February 8, 2023

See More About The Topic

Labor and Delivery

Ambulatory Clinic or Office

Health Care Providers

Health Care Executives and Administrators

Obstetrics