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The PSNet Collection: All Content

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.

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Displaying 1 - 8 of 8 Results
Combs CA, Goffman D, Pettker CM. Am J Obstet Gynecol. 2022;226:b2-b9.
Readmission reduction as an improvement measure has been found to be problematic as a maternal safety outcome. This statement shares concerns regarding incentivizing hospitalization reductions after birth and explores the potential for patient harm due to pressures to reduce readmissions when needed.
Pettker CM. Semin Perinatol. 2017;41.
Adverse events in obstetrics put both maternal and infant patients at risk. The first commentary in this series describes strategies to identify and classify events in obstetric care. The second article discusses how to respond to adverse events, such as root cause analysis, error disclosure, and peer support.
Pettker CM, Grobman WA. Obstet Gynecol. 2015;126:196-206.
Obstetric hospital admission has substantial potential for harm should something go wrong. Summarizing the unique characteristics of obstetric care that affect quality and safety, this commentary highlights strategies to improve safety in this setting, including Plan-Do-Study-Act cycles, simulation training, and crew resource management.
Pettker CM, Thung SF, Lipkind HS, et al. Am J Obstet Gynecol. 2014;211:319-25.
A comprehensive obstetric patient safety program at an academic hospital—which involved teamwork training, standardizing care protocols, and establishing a robust quality assurance mechanism (including a dedicated patient safety nurse and an anonymous error reporting system)—has previously been shown to decrease adverse events and improve safety culture. This follow-up study demonstrates that the program was also associated with a reduction in malpractice claims and total payments over a 5-year period. The relationship between patient safety and malpractice claims is complex, as claims data likely do not correlate with overall safety. However, the results of this study, along with other studies showing that full disclosure of adverse events can reduce malpractice claims, lends support to the belief that improving safety culture can have downstream effects on malpractice lawsuits at the health-system level.
Pettker CM, Thung SF, Norwitz ER, et al. Am J Obstet Gynecol. 2009;200:492.e1-8.
A multifaceted approach to patient safety resulted in improvements in both patient- and provider-related outcomes over a 3-year time frame. The strategy was developed after consultation with obstetric safety experts and included teamwork training, standardization of care protocols, and establishment of a robust quality assurance mechanism (including a dedicated patient safety nurse). Progressive implementation of the safety interventions was associated with a steady reduction in maternal and fetal adverse events, as well as improvement in the overall perception of safety culture (as measured by the Safety Attitudes Questionnaire). Prior research has demonstrated the effectiveness of crew resource management training in improving obstetric safety.