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 - 20 of 169 Results

Vital signs: maternity care experiences — United States, April 2023.

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Mohamoud YA, Cassidy E, Fuchs E, et al. MMWR Morb Mortal Wkly Rep. 2023;72:961–967.

Previous research has found that women often experience mistreatment and discrimination during maternity care. This CDC analysis of survey data for 2,402 respondents found that approximately one in five women experienced at least one type of mistreatment during maternity care (i.e., being ignored or refused, being shouted at or scolded, having their physical privacy violated). Nearly 29% of respondents reported experiencing at least one form of discrimination during their maternity care (i.e., age-, weight-, income-, or race/ethnicity-based discrimination).

Understanding and Improving Diagnostic Safety in Ambulatory Care.

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Rockville, MD: Agency for Healthcare Quality and Research; August 22, 2023.

The articulation of diagnostic error in the ambulatory setting is emerging. These newly released funding announcements seek proposals that focus on understanding the factors contributing to diagnostic error and strategies to improve diagnostic safety in the ambulatory care environment. The application deadline for both opportunities has passed.

Hiding in plain sight: inconvenient facts for patient safety in non-24/7 theatre on-site staffed obstetric units.

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McGurgan P. Aust N Z J Obstet Gynaecol. 2023;63:606-611.

Individual-, team-, and systems-based factors can affect safety during childbirth. This article discusses several patient safety threats that can hinder the safety of vaginal birth after cesarean (VAC) deliveries in high population density areas, including staffing and resource limitations, cultural and human factors, and patient communication.

Dangers and deaths around black pregnancies seen as a ‘completely preventable’ health crisis.

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West S. KFF Health News. August 24, 2023.

The challenge of unsafe maternal care is gaining deserved attention across the system spectrum. This article discusses the preventative nature of many barriers to safe care Black mothers face including lack of health insurance, limited access to prenatal care and disrespect for concerns during care encounters.

‘The Retrievals’ reveals painful experiences of female patients are often ignored.

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Desjardins L. PBS NewsHour. August 29, 2023.

Disregard for women’s pain is a persistent problem in health care. This news segment discusses a podcast highlighting a pattern of dismissal of patient concerns that resulted in harm and allowed fentanyl diversion by a nurse with substance abuse disorder to go undetected.

When the lights go down in the delivery room: lessons from a ransomware attack.

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Gabbay‐Benziv R, Ben‐Natan M, Roguin A, et al. Int J Gynaecol Obstet. 2023;162:562-568.

Cyberattacks on healthcare systems are a rare but serious threat to public and patient safety. This article describes one obstetric department's experience with a weeklong cyberattack. Nearly every aspect of clinical care and monitoring was impacted, particularly loss of historical health record and electronic fetal heartrate monitoring. Adaptations to these and other affected services are detailed.

Prolonged DKA in Pregnancy: A Case of Communication Breakdown.

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WebM&M Case August 30, 2023

A 31-year-old pregnant patient with type 1 diabetes on an insulin pump was hospitalized for euglycemic diabetic ketoacidosis (DKA). She was treated for dehydration and vomiting, but not aggressively enough, and her metabolic acidosis worsened over several days. The primary team hesitated to prescribe medications safe in pregnancy and delayed reaching out to the Maternal Fetal Medicine (MFM) consultant, who made recommendations but did not ensure that the primary team received and understood the information.

Quality and safety practices among academic obstetrics and gynecology departments.

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Christopher D, Leininger WM, Beaty L, et al. Am J Med Qual. 2023;38:165-173.

Staff engagement in safety and quality improvement efforts fosters a culture of safety and can reduce medical errors. This survey of 52 obstetrics and gynecology departments at academic medical centers found that few departments provided faculty with protected time or financial support for quality improvement activities, and only 5% of departments included a patient representative on the quality committee.

Amid lack of accountability for bias in maternity care, a California family seeks justice.

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Kwon S. KFF Health News. August 8, 2023

Implicit bias and systemic racism are known to affect the safety of Black maternal care. This story describes an incident of maternal death and the family’s effort to demonstrate the role of discrimination in the outcome and hold the clinicians and organization involved responsible.

Toolkits To Reduce Hypertension in Pregnancy and Obstetric Hemorrhage.

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Rockville, MD: Agency for Healthcare Research and Quality; July 2023.

Obstetric hemorrhage and severe high blood pressure during pregnancy are leading known causes of preventable maternal harms in the United States. The AHRQ Safety Program for Perinatal Care, Phase 2 developed toolkits consisting of case scenarios, slides, and facilitators guides to work in tandem to address these threats to maternal safety. The materials inform training opportunities to improve the safety culture of labor and delivery units and decrease maternal and neonatal adverse events that result from poor communication and system failures.

Investigating racial and ethnic disparities in maternal care at the system level using patient safety incident reports.

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Alfred MC, Wilson D, DeForest E, et al. Jt Comm J Qual Patient Saf. 2023;Epub Jun 15.

In the United States, women and birthing people of color experience disproportionately high rates of mortality and severe maternal morbidity (SMM). Researchers analyzed two years of incident reports (IR) to ascertain potential system issues contributing to SMM and racial/ethnic disparities at one hospital. Non-Hispanic Black individuals were over-represented in IRs, but there were no statistically significant differences in harm level.

The Retrievals.

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Burton S. New York Times and Serial Productions. June 30-July 27, 2023.

Unnoticed drug diversion can result in harm to patients, clinicians, and organizations. This series describes how diversion contributed to unnecessary pain in fertility clinic patients. The problem was compounded by a lack of attention to women voicing their concerns about procedural pain.

Statewide perinatal quality improvement, teamwork, and communication activities in Oklahoma and Texas.

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Stierman EK, O'Brien BT, Stagg J, et al. Qual Manag Health Care. 2023;32:177-188.

Maternal morbidity and mortality remain a significant problem in U.S. health care. This article describes Texas and Oklahoma’s adoption of a perinatal quality improvement initiative, including the implementation of the Alliance for Innovation of Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units. Findings suggest that adoption of initiative components varies across obstetric units; the majority of units had standardized processes for serious events (obstetric hemorrhage, massive transfusion, severe hypertension) but fewer units offered regular training on effective teamwork and communication for their staff.

Interdisciplinary and interprofessional communication intervention: how psychological safety fosters communication and increases patient safety.

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Dietl JE, Derksen C, Keller FM, et al. Front Psychol. 2023;14:1164288.

Psychological safety can support high-quality teamwork and communication. This article reports on perceived patient and psychological safety following an interprofessional obstetrical communication and psychological safety training as part of the TeamBaby research project. After the training, perceived patient safety risks were lower.

A national analysis of ED presentations for early pregnancy and complications: implications for post-Roe America.

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Goodwin G, Marra E, Ramdin C, et al. Am J Emerg Med. 2023;70:90-95.

When the US Supreme Court overturned Roe v. Wade, access to safe reproductive care was restricted even for patients with wanted or non-viable pregnancies. This study describes trends in early pregnancy-related emergency department visits prior to the court decision and how new restrictions have resulted in physician uncertainty and delays in care in states with abortion bans. The authors recommend physicians be mindful of Emergency Medical Treatment and Active Labor Act (EMTALA) when caring for pregnant individuals in the emergency department.

Trends in maternal mortality and severe maternal morbidity during delivery-related hospitalizations in the United States, 2008 to 2021.

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Fink DA, Kilday D, Cao Z, et al. JAMA Netw Open. 2023;6:e2317641.

Ensuring all pregnant individuals receive safe maternal care is a national health priority. Using a large national database, this study describes trends in delivery-related severe maternal morbidity (SMM) and mortality in the United States. Maternal mortality decreased for all racial, ethnic, and age groups, while SMM increased for all groups, particularly racial and ethnic minoritized groups. Patients with COVID-19 had a significantly increased risk of death. PSNet features a curated library of maternal safety resources.

Advancing Diagnostic Excellence in Maternal Health Care.

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Board on Health Care Services, National Academies of Science, Engineering, and Medicine. Arnold and Mabel Beckman Center, Irvine, CA. July 27, 2023.

Misdiagnosis during pregnancy can have tragic results for both the pregnant person and infant. This free workshop will discuss current challenges in maternal diagnostic excellence, identifications of knowledge gaps, and strategies to decrease maternal disparities. The workshop is open to the public can be attended in-person or virtually.

‘I felt like I was dying’: how women with postpartum depression fall through the cracks of U.S. health care.

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Gammon K. STAT. June 26, 2023.

The maternal mental health crisis results in harm to mothers and their families. This article discusses systemic issues that impact the safe psychological care of mothers from pregnancy through the years of caring for toddlers. Lack of timely diagnosis is a major consideration discussed.

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

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WebM&M Case June 28, 2023

A 25-year-old obese patient required an emergency cesarean delivery. As the obstetric team was in a hurry to deliver the baby, the team huddle was rushed. After the delivery, the anesthesia care provider discovered that the patient had received subcutaneous enoxaparin 40 mg four hours preoperatively, which was not mentioned by the obstetric team during the previous huddle.

Causes for medical errors in obstetrics and gynaecology.

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Klemann D, Rijkx M, Mertens H, et al. Healthcare (Basel). 2023;11:1636.

Reducing maternal morbidity and mortality is a global patient safety goal. This systematic review identified three categories of direct and indirect risk factors of maternal safety: delay of care, coordination and management of care, and scarcity of supply, personnel, and knowledge. The risk factors varied between developed and developing countries.

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