Journal Article
Study

A multidisciplinary model for reviewing severe maternal morbidity cases and teaching residents patient safety principles.

Ogunyemi D, Hage N, Kim SK, et al. Joint Commission journal on quality and patient safety. 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.