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

Paul McGurgan

Commentary

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

September 6, 2023

McGurgan P. Aust N Z J Obstet Gynaecol. 2023;63(4):606-611.

View more articles from the same authors.

Individual-, team-, and systems-based factors can affect safety during childbirth. This article discusses several patient safety threats that can hinder the safety of vaginal birth after cesarean (VAC) deliveries in high population density areas, including staffing and resource limitations, cultural and human factors, and patient communication.

PubMed citation

Available at

Related Resources From the Same Author(s)

Why is patient safety a challenge? Insights from the Professionalism Opinions of Medical Students' research.

November 2, 2022

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

March 15, 2023

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

Nurse Staffing Levels, Missed Vital Signs and Mortality in Hospitals: Retrospective Longitudinal Observational Study.

December 19, 2018

Impact of introducing an electronic physiological surveillance system on hospital mortality.

October 15, 2014

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

August 13, 2014

Burnout and medical errors among American surgeons.

December 9, 2009

Persistent next-day effects of excessive alcohol consumption on laparoscopic surgical performance.

May 4, 2011

Resident participation does not affect surgical outcomes, despite introduction of new techniques.

September 22, 2010

Measuring perceptions of safety climate in primary care: a cross-sectional study.

February 29, 2012

Do physicians know when their diagnoses are correct? Implications for decision support and error reduction.

September 7, 2005

Racial and ethnic differences in emergency department diagnostic imaging at US Children's Hospitals, 2016-2019.

January 4, 2021

Critical care teamwork in the future: the role of TeamSTEPPS in the COVID-19 pandemic and implications for the future.

March 15, 2023

A systems analysis of work-related violence in hospitals: stakeholders, contributory factors, and leverage points.

February 22, 2023

Understanding context specificity: the effect of contextual factors on clinical reasoning.

September 2, 2020

Adverse events related to accidental unintentional ingestions from cough and cold medications in children.

August 26, 2020

Nonoperating room anaesthesia: safety, monitoring, cognitive aids and severe acute respiratory syndrome coronavirus 2.

August 12, 2020

Accuracy of emergency department clinical findings for diagnosis of coronavirus disease 2019.

July 29, 2020

The impact of power on health care team performance and patient safety: a review of the literature.

April 21, 2021

Management and patient safety of complex elderly patients in primary care during the COVID-19 pandemic in the UK-Qualitative assessment.

April 14, 2021

Assessment of patients' ability to review electronic health record information to identify potential errors: cross-sectional web-based survey.

March 10, 2021

Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety.

February 24, 2021

Measurement and monitoring patient safety in prehospital care: a systematic review.

February 24, 2021

The I-READI quality and safety framework: a health system’s response to airway complications in mechanically ventilated patients with Covid-19.

February 17, 2021

Establishing a multi-institutional quality and patient safety consortium: collaboration across affiliates in a community-based medical school.

January 20, 2021

Effects of night surgery on postoperative mortality and morbidity: a multicentre cohort study.

December 23, 2020

Guidance for health care leaders during the recovery stage of the COVID-19 pandemic: a consensus statement.

July 28, 2021

How safe is prehospital care? A systematic review.

November 17, 2021

Identifying hot spots for harm and blind spots across the care pathway from patient complaints about general practice.

November 3, 2021

Quantifying discharge medication reconciliation errors at 2 pediatric hospitals.

October 27, 2021

The relationship between high-reliability practice and hospital-acquired conditions among the Solutions for Patient Safety Collaborative.

October 20, 2021

Factors associated with potentially missed acute deterioration in primary care: cohort study of UK general practices.

October 20, 2021

Descriptive analysis of patient misidentification from incident report system data in a large academic hospital federation.

October 20, 2021

Institution of just culture physician peer review in an academic medical center.

October 13, 2021

Is there a mismatch between the perspectives of patients and regulators on healthcare quality? A survey study.

October 6, 2021

A dynamic risk management approach for reducing harm from invasive bedside procedures performed during residency.

September 22, 2021

Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients.

September 22, 2021

Long-term effects of teamwork training on communication and teamwork climate in ambulatory reproductive health care.

October 28, 2020

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

October 7, 2020

Preventing home medication administration errors.

March 14, 2022

Situation awareness and the mitigation of risk associated with patient deterioration: a meta-narrative review of theories and models and their relevance to nursing practice.

December 1, 2021

A meta-review of methods of measuring and monitoring safety in primary care.

September 15, 2021

Interventions targeted at reducing diagnostic error: systematic review.

September 8, 2021

Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial.

August 18, 2021

Effectiveness and safety of pulse oximetry in remote patient monitoring of patients with COVID-19: a systematic review.

April 20, 2022

Overall performance of a drug-drug interaction clinical decision support system: quantitative evaluation and end-user survey.

April 13, 2022

Economic evaluation of quality improvement interventions to prevent catheter-associated urinary tract infections in the hospital setting: a systematic review.

March 30, 2022

Cost of health care-associated infections in the United States.

March 23, 2022

State of science: evolving perspectives on ‘human error’.

March 16, 2022

Key use cases for artificial intelligence to reduce the frequency of adverse drug events: a scoping review.

March 9, 2022

Reliability, uncertainty and the management of error: new perspectives in the COVID-19 era.

March 9, 2022

Show me the money, I'll show you my complications: impacts of incentivized incident self-reporting among surgeons.

March 2, 2022

Factors influencing diagnostic accuracy among intensive care unit clinicians - an observational study.

January 24, 2024

Methods for studying medication safety following electronic health record implementation in acute care: a scoping review.

January 10, 2024

Team debriefing in the COVID-19 pandemic: a qualitative study of a hospital-wide clinical event debriefing program and a novel qualitative model to analyze debriefing content.

November 16, 2022

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

November 16, 2022

Eight human factors and ergonomics principles for healthcare artificial intelligence.

November 2, 2022

Association of rapid response teams with hospital mortality in Medicare patients.

October 19, 2022

Testimonial injustice: linguistic bias in the medical records of black patients and women.

June 6, 2021

Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery.

October 5, 2022

Understanding teamwork in rapidly deployed interprofessional teams in intensive and acute care: a systematic review of reviews.

September 28, 2022

Automated search methods for identifying wrong patient order entry-a scoping review.

August 23, 2023

Association between electronic health record implementations and hospital-acquired conditions in pediatric hospitals.

August 2, 2023

Antimicrobial residual drug error in the intensive care unit; a single blinded prospective observational study.

July 26, 2023

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

Evidence for anchoring bias during physician decision-making.

July 12, 2023

Prevalence of potentially inappropriate medication prescribing in US nursing homes, 2013-2017.

July 5, 2023

Quality measures for patients at risk of adverse outcomes in the Veterans Health Administration: expert panel recommendations.

August 17, 2022

Association between hospital acquired harm outcomes and membership in a national patient safety collaborative.

August 10, 2022

The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study.

August 10, 2022

Trends in adverse event rates in hospitalized patients, 2010-2019.

July 27, 2022

Frailty, gaps in care coordination, and preventable adverse events.

July 6, 2022

Nonopioid directives: unintended consequences in the operating room.

June 29, 2022

Healthcare resilience: a meta-narrative systematic review and synthesis of reviews.

October 11, 2023

Problems and paradoxes of reliability and resilience in organizational networks.

September 20, 2023

Changes in medication safety indicators in England throughout the covid-19 pandemic using OpenSAFELY: population based, retrospective cohort study of 57 million patients using federated analytics.

June 7, 2023

The impact of nursing skill-mix on adverse events in intensive care: a single centre cohort study.

May 31, 2023

Towards a unified model of accident causation: refining and validating the systems thinking safety tenets.

May 10, 2023

Diagnostic challenges in primary care: identifying and avoiding cognitive bias.

June 29, 2022

Wellbeing, burnout, and safe practice among healthcare professionals: predictive influences of mindfulness, values, and self-compassion.

June 8, 2022

Safety gaps in medical team communication: closing the loop on quality improvement efforts in the cardiac catheterization lab.

June 8, 2022

The patient's "story": an examination of patient-reported safety incidents in general practice.

May 4, 2022

Understanding complexity in a safety critical setting: a systems approach to medication administration.

April 26, 2023

Not sick enough to worry? "Influenza-like" symptoms and work-related behavior among healthcare workers and other professionals: results of a global survey.

June 3, 2020

Using social and behavioural science to support COVID-19 pandemic response.

June 3, 2020

A systematic review of patient-report safety climate measures in health care.

May 27, 2020

A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings.

February 8, 2017

Reevaluation of diagnosis in adults with physician-diagnosed asthma.

February 1, 2017

Identification of priorities for improvement of medication safety in primary care: a PRIORITIZE study.

December 14, 2016

Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex systems.

December 14, 2016

Economic evaluation of quality improvement interventions for bloodstream infections related to central catheters: a systematic review.

January 25, 2017

Trends in anesthesia-related liability and lessons learned.

March 6, 2019

Important factors for effective patient safety governance auditing: a questionnaire survey.

January 30, 2019

Predictors of adverse events and medical errors among adult inpatients of psychiatric units of acute care general hospitals.

January 30, 2019

Diagnostic error in the critically ill: defining the problem and exploring next steps to advance intensive care unit safety.

October 24, 2018

Impact of teamwork improvement training on communication and teamwork climate in ambulatory reproductive health care.

May 1, 2019

Patient safety skills in primary care: a national survey of GP educators.

February 4, 2015

Implementation of a standardized postanesthesia care handoff increases information transfer without increasing handoff duration.

January 14, 2015

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

January 21, 2015

Debriefing in the emergency department after clinical events: a practical guide.

December 17, 2014

Related Resources

"Black Women Should Not Die Giving Life": The lived experiences of Black women diagnosed with severe maternal morbidity in the United States.

April 17, 2024

A qualitative study of systems-level factors that affect rural obstetric nurses' work during clinical emergencies.

February 21, 2024

Sustained decrease in latent safety threats through regular interprofessional in situ simulation training of neonatal emergencies.

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

Neonatal near-miss audits: a systematic review and a call to action.

January 10, 2024

Team experiences of the root cause analysis process after a sentinel event: a qualitative case study.

November 29, 2023

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

October 11, 2023

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

September 6, 2023

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

September 6, 2023

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

September 6, 2023

Interview

In Conversation with... Kathleen Sanford and Sue Schuelke about Virtual Nursing

August 30, 2023

Perspectives on Safety

Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges

August 30, 2023

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

August 16, 2023

Statewide perinatal quality improvement, teamwork, and communication activities in Oklahoma and Texas.

July 26, 2023

A national analysis of ED presentations for early pregnancy and complications: implications for post-Roe America.

July 19, 2023

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

July 5, 2023

Black women's maternal health: insights from community based participatory research in Newark, New Jersey.

June 29, 2023

After Roe: Challenges in the Provision of Lifesaving Care.

June 21, 2023

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

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

Hospitals in two states denied an abortion to a miscarrying patient. Investigators say they broke federal law.

May 31, 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

Attitudes of clinicians and patient safety culture before and after the ARRIVE trial.

May 24, 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

Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2023.

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

See More About The Topic

Hospitals

Labor and Delivery

Obstetrics

Neonatology and Intensive Care

Public Health

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

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

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

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