People of color experience disproportionately higher rates of maternal morbidity and mortality. As part of a larger quality improvement and patient safety initiative to reduce severe maternal morbidity from hemorrhage (SMM-H), this hospital analyzed administrative data stratified by race and ethnicity, and noted a disparity between White and Black patients. Review of this data was integrated with the overall improvement bundle. Post-implementation results show that SMM-H rates for Black patients decreased.

This article describes the development of the Universal Protection Framework, which builds upon traditional infection prevention practices and consists of four domains (infection prevention, access control, distancing, and patient flow) supported by communication and education. The framework was implemented in one large health system with high levels of compliance, particularly for handling of personal protective equipment (PPE), cohorting of COVID-19 patients, facility access controls and employee exposure monitoring.

… of pressure ulcers in hospitalized patients using a multimodal intervention that included providing performance … declined in participating facilities, demonstrating that a quality improvement model can enhance patient safety. …

… … Am J Obstet Gynecol … Checklists are considered a key tool for improving communication and safety in risky, … of checklists, design elements to consider when developing a checklist, and strategies to implement checklists. …

… Gynecol … Although peer review has been advocated as a valuable method for improving quality and practice, it has …

Venous thromboembolism (VTE) is a preventable condition that can contribute to maternal harm. This expert commentary introduces a four-part strategy that focuses on standardization to help recognize and respond to VTE. The authors discuss the importance of reporting mechanisms to help health care organizations learn from events.

… to harm associated with its use. This commentary describes a comprehensive analysis that identified risks related to … delivery and recommends solutions to enhance its safety. … Perlin JB, Mower L, Bushe C. A systems approach to evaluating ionizing …

… N Engl J Med … Healthcare associated infection is a leading cause of preventable illness and death. … Methicillin-resistant Staphylococcus aureus (MRSA) is a virulent, multi-drug resistant infection increasingly seen …

This analysis of more than 200,000 normal births found that the most common near misses (medication errors and patient identification errors) were easily preventable and had low potential for harm. In contrast, near misses involving physician responsiveness and decision-making were rare, but potentially much more harmful to patients.

This article reviews the physiological effects of sleep deprivation and describes how it affects labor and delivery practice.

… medical informatics … Int J Med Inform … Implementation of a computerized provider order entry system in a community hospital resulted in improved adherence to safe …

This article describes how one large, private health care system improved the safety of obstetric practice using principles of high reliability.

… … N Engl J Med … This study demonstrated the impact of a system-wide reengineering initiative on performance in the … attributed to the use of information technology systems, a model for integration of patient care services, and … care systems and the business case for quality and safety. A leader in these arenas, the VA has also developed …