Labor and delivery is an inherently high-risk care setting. The Agency for Healthcare Research and Quality adapted its Comprehensive Unit-based Safety Program, a best practice toolkit incorporating teamwork, human factors engineering principles, and simulation training, for labor and delivery. In this pre–post evaluation study, staff reported improved safety culture and teamwork. Obstetric trauma and primary cesarean delivery rates declined after the intervention, but neonatal birth trauma rates increased. The authors note that incomplete implementation and lack of sustained program participation observed in the study should be addressed in order to improve obstetric and neonatal care safety. A recent Annual Perspective emphasizes the rising rate of severe maternal morbidity and summarizes national initiatives to improve safety in maternity care.

… Decis Mak … AHRQ's Safety Program for Perinatal Care used a multifaceted approach based on the comprehensive unit-based … technology to enable implementation of the program. A variety of uses for health IT were described, including …

Learning collaboratives are multimodal interventions that are often used to implement evidence-based practices. This perspective from AHRQ scientists proposes a taxonomy to describe collaboratives' distinct elements: innovation, or the type of positive change; communication among members; duration and sustainability; and social systems, or the organization and culture of the collaborative. The authors suggest that efforts to evaluate learning collaboratives or quality improvement interventions employ this taxonomy.

An inconvenient truth about the patient safety movement is that in many cases hospitals actually profit when errors occur. A recent study found that hospitals received greater net reimbursements for patients who experienced surgical complications compared with patients whose surgeries were uncomplicated. This study examined the financial impact of an effort to eliminate obstetric complications in a five-hospital health system. The project led to an 11% reduction in preventable adverse events, but hospital reimbursements decreased considerably as a result—meaning that although costs were saved, the hospitals' net revenues declined overall. This finding represents a classic case of misaligned incentives: the outcome was beneficial for payers and patients (who received higher quality care at lower cost) but not directly beneficial for hospitals (who shouldered the cost of implementing the intervention but lost revenue as a result). As the return on investment for safety interventions such as computerized provider order entry is marginal at best, payment system reform to align incentives will be necessary in order to improve the business case for safety.

… failures to result in preventable patient harm. Despite a rich body of literature exploring cognitive biases that … settings. This group of authors also recently published a review of system interventions to prevent diagnostic errors. …

… Patient Saf … This commentary describes the development of a collaborative change package for improving patient safety …

… problems, and this narrative review sought to develop a taxonomy of diagnostic error dimensions and identify …

This study conducted adult discussion groups to draw conclusions about the greater attention required for medication safety counseling at outpatient pharmacies.