The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Fridman M, Korst LM, Reynen DJ, et al. Jt Comm J Qual Patient Saf. 2023;49:129-137.
Severe maternal morbidity (SMM) is an international public health concern and the focus of hospital quality improvement activities. This article describes the development of a performance SMM (pSMM) that can be used to quantify potentially preventable, hospital-acquired SMM. The Centers for Disease Control and Prevention (CDC) SMM measure was adapted and results are stratified by hospital type.
Ozimek JA, Greene N, Geller AI, et al. Am J Perinatol. 2022;39:307-311.
Maternal morbidity and mortality remains a major public health concern, particularly among pregnant people of color. This US hospital established a multi-disciplinary committee, the obstetric Quality and Peer Review Committee (OBQPRC), to review all cases of severe maternal morbidity (SMM). This article compares the pre- and post-intervention periods to determine if rates of potentially preventable SMM decreased. While there was no difference in SMM rates pre- and post-intervention, the rate of potentially preventable events significantly decreased after implementation of routine review of all SMM.
First admitted to the hospital at 25 weeks of pregnancy for vaginal bleeding, a woman (G5 P2 A2) received 4 units of packed red blood cells and 2 doses of iron injections. She was discharged after 3 days with an improved hemoglobin level. At 35 weeks, she was admitted for an elective cesarean delivery. Intraoperatively, an upper uterine segment incision was made and the newborn was delivered in good condition. Immediately after, a subtotal hysterectomy was performed. The anesthesiologist noted that the patient was hypotensive; blood was transfused.