A series of anesthesia-related maternal deaths in Michigan, 1985-2003.

Jill M. Mhyre; Monica N. Riesner; Linda S. Polley; Norah N. Naughton

Study

A series of anesthesia-related maternal deaths in Michigan, 1985-2003.

July 18, 2007

Mhyre JM, Riesner MN, Polley LS, et al. Anesthesiology. 2007;106(6):1096-1104.

View more articles from the same authors.

The researchers retrospectively analyzed cases of pregnancy-associated deaths involving anesthesia care and found that system errors, lapses in monitoring, and inadequate supervision by anesthesiologists were factors in the deaths.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Ambiguous abbreviations: an audit of abbreviations in paediatric note keeping.

April 30, 2008

A comprehensive collaborative patient safety residency curriculum to address the ACGME core competencies.

December 14, 2005

Improving operating room safety.

December 16, 2009

Eliminating explicit and implicit biases in health care: evidence and research needs.

February 23, 2022

Computerized clinical decision support during medication ordering for long-term care residents with renal insufficiency.

July 22, 2009

The incidence of adverse drug events in two large academic long-term care facilities.

April 15, 2005

Error and patient safety: ethical analysis of cases in occupational and physical therapy practice.

March 7, 2007

Medical errors: where are we now?

November 15, 2006

Start using a checklist, PRONTO: recommendation for a standard review process for chemotherapy orders.

March 13, 2019

Organisational strategies to implement hospital pressure ulcer prevention programmes: findings from a national survey.

September 21, 2016

Exploring pharmacist experiences of delivering individualised prescribing error feedback in an acute hospital setting.

January 16, 2019

Exploring attitudes and opinions of pharmacists toward delivering prescribing error feedback: a qualitative case study using focus group interviews.

November 4, 2015

Medication errors in neonatal and paediatric intensive-care units.

March 6, 2005

Automated dispensing cabinets.

August 15, 2007

Residents' reflections on quality improvement: temporal stability and associations with preventability of adverse patient events.

May 18, 2011

Keeping patients safe in healthcare organizations: a structuration theory of safety culture.

May 11, 2011

Physician satisfaction with transition from CPOE to paper-based prescription.

July 12, 2017

Intensive care unit nurses' perceptions of safety after a highly specific safety intervention.

February 20, 2008

Excess mortality caused by medical injury.

November 8, 2006

Parents' perspectives on navigating the work of speaking up in the NICU.

November 8, 2017

Nurse staffing, burnout, and health care-associated infection.

August 15, 2012

Failure to weigh patients in hospital: a medication safety risk.

September 12, 2007

Extent of diagnostic agreement among medical referrals.

April 12, 2017

Parents' perspective on safety in neonatal intensive care: a mixed-methods study.

July 23, 2014

Clinical application of a computerized system for physician order entry with clinical decision support to prevent adverse drug events in long-term care.

January 18, 2006

Computerized physician order entry with clinical decision support in the long-term care setting: insights from the Baycrest Centre for Geriatric Care.

October 26, 2005

Using medical malpractice closed claims data to reduce surgical risk and improve patient safety.

April 25, 2007

Using simulation to improve first-year pharmacy students' ability to identify medication errors involving the top 100 prescription medications.

August 24, 2016

Inter- and intra-rater reliability for classification of medication related events in paediatric inpatients.

June 21, 2006

The incidence and nature of in-hospital adverse events: a systematic review.

June 18, 2008

Development and validation of the SURgical PAtient Safety System (SURPASS) checklist.

April 22, 2009

Association of hospital participation in a regional trauma quality improvement collaborative with patient outcomes.

June 20, 2018

Understanding patient safety and quality outcome data.

March 20, 2019

Safeguarding patients: complexity science, high reliability organizations, and implications for team training in healthcare.

December 20, 2006

Improving patient safety: patient-focused, high-reliability team training.

September 10, 2008

U.S. adoption of computerized physician order entry systems.

November 30, 2005

An experimental study in nurse-physician relationships.

August 2, 2006

Evaluation of a physician informatics tool to improve patient handoffs.

July 29, 2009

Impact of the nurse shortage on hospital patient care: comparative perspectives.

July 25, 2007

Reevaluating the safety profile of pediatrics: a comparison of computerized adverse drug event surveillance and voluntary reporting in the pediatric environment.

June 4, 2008

Medication handling: towards a practical, human-centred approach.

April 3, 2019

Risk of misdiagnosis and delayed diagnosis with COVID-19: a syndemic approach.

February 10, 2021

Assessing content validity and user perspectives on the Team Check-up Tool: expert survey and user focus groups.

April 5, 2017

Impact of the World Health Organization's Surgical Safety Checklist on safety culture in the operating theatre: a controlled intervention study.

July 10, 2013

An educational intervention to increase "speaking-up" behaviors in nurses and improve patient safety.

January 11, 2012

A qualitative study examining the influences on situation awareness and the identification, mitigation and escalation of recognised patient risk.

January 29, 2014

Rapid response teams: qualitative analysis of their effectiveness.

June 19, 2013

Citation classics in patient safety research: an invitation to contribute to an online bibliography.

November 22, 2006

A national survey of obstetric anaesthetic handovers.

April 5, 2006

Patient safety in cataract surgery.

July 20, 2005

Challenges in posthospital care: nurses as coaches for medication management.

August 24, 2011

John M. Eisenberg Patient Safety Awards. Advocacy: the Lexington Veterans Affairs Medical Center.

March 27, 2005

Validating patient safety in the endoscopy unit using The Joint Commission standards.

July 13, 2011

Five pitfalls in decisions about diagnosis and prescribing.

November 2, 2005

Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project.

August 18, 2010

An educational and audit tool to reduce prescribing error in intensive care.

October 29, 2008

Qualities and attributes of a safe practitioner: identification of safety skills in healthcare.

January 26, 2011

Journal Article

Study

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

March 29, 2023

Framework for analysing risk and safety in clinical medicine.

July 17, 2013

Framework for analysing risk and safety in clinical medicine.

July 17, 2013

Development of a rating system for surgeons' non-technical skills.

November 8, 2006

Attitudes to teamwork and safety in the operating theatre.

June 28, 2006

Diagnostic delays and errors in head and neck cancer patients: opportunities for improvement.

April 27, 2016

"We're not taken seriously": describing the experiences of perceived discrimination in medical settings for Black women.

March 22, 2023

Participation in a system-thinking simulation experience changes adverse event reporting.

July 8, 2020

Simulation based adverse event reporting system: development and feasibility.

July 30, 2014

12 h shifts and rates of error among nurses: a systematic review.

August 5, 2015

Safety huddles in the PACU: when a patient self-medicates.

April 6, 2011

Medication reconciliation at an academic medical center: implementation of a comprehensive program from admission to discharge.

December 9, 2009

Nursing time devoted to medication administration in long-term care: clinical, safety, and resource implications.

March 18, 2009

Reducing medical errors and adverse events.

February 8, 2012

Electronic prescribing improves medication safety in community-based office practices.

March 17, 2010

The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical learning environment.

July 14, 2021

Parents' medication administration errors: role of dosing instruments and health literacy.

February 10, 2010

Medication safety program reduces adverse drug events in a community hospital.

June 22, 2005

A multifaceted approach to safety: the synergistic detection of adverse drug events in adult inpatients.

September 17, 2008

Resident to resident handoffs in the emergency department: an observational study.

October 22, 2014

The novice nurse and clinical decision-making: how to avoid errors.

May 11, 2011

Management of arterial lines and blood sampling in intensive care: a threat to patient safety.

January 8, 2014

Effect of day of the week on short- and long-term mortality after emergency general surgery.

April 5, 2017

The association of hospital quality ratings with adverse events.

February 26, 2014

Performance of a fail-safe system to follow up abnormal mammograms in primary care.

September 8, 2010

Medication safety pharmacy technician in a large, tertiary care, community hospital.

March 30, 2016

Higher quality of care and patient safety associated with better NICU work environments.

September 2, 2015

Scrutinizing incident reporting in anaesthesia: why is an incident perceived as critical?

September 13, 2006

Patient safety and the ageing physician: a qualitative study of key stakeholder attitudes and experiences.

October 10, 2018

Examining variations in prescribing safety in UK general practice: cross sectional study using the Clinical Practice Research Datalink.

November 25, 2015

Achieving quality improvement in the nursing home: influence of nursing leadership on communication and teamwork.

March 9, 2011

Trends and patterns in reporting of patient safety situations in transplantation.

February 10, 2016

Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments.

January 25, 2012

Disclosure of hospital adverse events and its association with patients' ratings of the quality of care.

November 18, 2009

Effectiveness of random and focused review in detecting surgical pathology error.

January 14, 2009

Can we rely on patients' reports of adverse events?

June 22, 2011

Identifying barriers to the effective use of clinical reminders: bootstrapping multiple methods.

June 1, 2005

Prescribing discrepancies likely to cause adverse drug events after patient transfer.

February 25, 2009

The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction.

April 23, 2012

Hospital at Home: setting a regulatory course to ensure safe, high-quality care.

February 2, 2022

Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting.

February 11, 2009

Measuring inappropriate medical diagnosis and treatment in survey data: the case of ADHD among school-age children.

February 23, 2011

Establishing a simulation center for surgical skills: what to do and how to do it.

September 12, 2007

Related Resources

Research from webAIRS incident reporting system.

November 29, 2023

WebM&M Cases

Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia.

August 30, 2023

WebM&M Cases

Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery.

June 28, 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

Racial bias in cesarean decision-making.

May 10, 2023

Journal Article

Study

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

March 29, 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

Accuracy of spinal anesthesia drug concentrations in mixtures prepared by anesthetists.

January 11, 2023

HSIB Maternity Investigation Programme Year in Review 2021/22. Summary of Highlights, Themes and Future Work.

September 21, 2022

Medical malpractice lawsuits involving trainees in obstetrics and gynecology in the USA.

September 21, 2022

Association of provider specialty with abortion-related morbidity and adverse events among patients having procedural and medication abortions.

August 10, 2022

A new index for obstetrics safety and quality of care: integrating cesarean delivery rates with maternal and neonatal outcomes.

June 1, 2022

The effects of leadership curricula with and without implicit bias training on graduate medical education: a multicenter randomized trial.

May 18, 2022

Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity.

May 4, 2022

Improving communication and teamwork during labor: a feasibility, acceptability, and safety study.

March 16, 2022

Healing our own: a randomized trial to assess benefits of peer support.

February 2, 2022

Psychometric properties of the perinatal missed care survey and missed care during labor and birth.

January 19, 2022

Preventing pregnancy-related mental health deaths: insights from 14 US maternal mortality review committees, 2008-17.

October 20, 2021

Association of simulation training with rates of medical malpractice claims among obstetrician-gynecologists.

October 13, 2021

Perspective

Health Equity and Maternal Health

October 6, 2021

Interview

In Conversation With….Alison Stuebe, MD, MSc and Kristin Tully, PhD

October 6, 2021

Decreased incidence of cesarean surgical site infection rate with hospital-wide perioperative bundle.

September 29, 2021

Communication failures contributing to patient injury in anaesthesia malpractice claims.

September 1, 2021

Wrong-patient orders in obstetrics.

July 28, 2021

Secondary traumatic stress in ob-gyn: a mixed methods analysis assessing physician impact and needs.

July 21, 2021

The implementation of communication didactics for OB/GYN residents on the disclosure of adverse perioperative events.

July 7, 2021

Comparison of methods to reduce bias from clinical prediction models of postpartum depression.

May 12, 2021

Each Baby Counts.

April 1, 2021

Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective cohort study.

February 17, 2021

The impact of critical incidents on nurses and midwives: a systematic review.

February 10, 2021

See More About The Topic

Labor and Delivery

Anesthesiology

Obstetrics

Surgical Complications

Epidemiology of Errors and Adverse Events

A series of anesthesia-related maternal deaths in Michigan, 1985-2003.

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

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

A series of anesthesia-related maternal deaths in Michigan, 1985-2003.

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

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