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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 - 20 of 118 Results
Healy A, Davidson C, Allbert J, et al. Am J Obstet Gynecol. 2022;Epub Dec 5.
The demand for, and acceptance of, telemedicine solutions to provide services has grown substantially in recent years as safety profiles for the services are being defined. This guideline examines its use in pregnancy-related care, discusses the benefits and suggests actions to ensure patient safety during these encounters such as development of appropriate metrics and methods for vital-sign monitoring.
Van der Voorden M, Ahaus K, Franx A. BMJ Open. 2023;13:e063175.
Patient engagement in healthcare is widely encouraged, but findings from some studies suggest that patient participation can have negative effects. This qualitative study with 16 patients and obstetric healthcare professionals examined the negative effects of patient participation in healthcare. Researchers identified four types of negative consequences from patient participation in safety – decreases in patient confidence, eroding of the patient-professional relationship, unwanted increases in patient responsibility, and excess time spent by professionals on the patient.
Kwon CS, Duzyj C. Am J Perinatol. 2022;Epub Dec 30.
Effective teamwork is critical for patient safety and numerous training strategies exist for improving team dynamics. The labor and delivery unit of an American hospital offered Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) training to all physicians and nurses on the ward, and assessed perceptions of teamwork and safety both before and six months after training. Results were mixed, and physician and nurse perceptions of safety significantly differed.
Byrd TE, Ingram LA, Okpara N. Womens Health (Lond). 2022;18:174550572211338.
Maternal near misses are associated with lower quality of life and poorer outcomes for the pregnant person and their family. In this study, 12 Black women who experienced a maternal near miss describe major contributors. They list communication problems, such as not being believed, their relationship with their provider, and provider discrimination as major contributors.

Eldeib D. ProPublica. November 13, 2022.

Pregnancy is recognized as a high-risk condition for both mother and infant. This news story examines the potential for stillbirth and its preventability. Lack of respect for the concerns of mothers, inadequate attention to research, and poor patient education are discussed as contributors to stillbirth.

Kirkup B. Department of Health and Social Care. London, England: Crown Copyright; 2022.  ISBN: 9781528636759.

Maternity care is beset with challenges that reduce safety. This analysis provided insights into improving maternity care in the British National Health Service (NHS) focusing on the need for identification of inadequate performance, enhanced sympathetic care, common purpose in teams, honest response to difficulties and effective outcome measurement.
Brown TH, Homan PA. Health Serv Res. 2022;57:443-447.
Structural racism, from race-adjusted algorithms to biased machine learning, contributes to and exacerbates health inequities. This commentary calls for developing valid measures of structural racism and a publicly available data infrastructure for researchers. A related study examined the relationship between structural racism and birth outcomes between Black and white patients in Minnesota.
Ghaith S, Campbell RL, Pollock JR, et al. Healthcare (Basel). 2022;10:1328.
Obstetric and gynecologic (OB/GYN) physicians are frequently involved in malpractice lawsuits, some of which result in catastrophic payouts. This study categorized malpractice claims involving OB/GYN trainees (students, residents, and fellows) between 1986 and 2020. Cases are categorized by type of injury, patient outcome, category of error, outcome of lawsuit, and amount of settlement.

Farnborough, UK: Healthcare Safety Investigation Branch; 2022. HSIB Report no. NI-005831

This report summarizes the work of an independent office that examines maternity care safety lapses in the United Kingdom. It discusses the number of investigations done, criteria for investigation selection and primary improvement themes drawn from the review of 706 investigations in the period covered which include clinical assessment and oversight, care escalation, and fetal monitoring. The report outlines the goal to establish a maternity review effort as an independent entity in 2023.
Taylor DJ, Goodwin D. J Med Ethics. 2022;48:672-677.
Normalization of deviance describes a situation where individuals, teams or organizations accept a lower standard of performance until that lower standard becomes the “norm” and can threaten patient safety. This article describes five serious medical errors in obstetrics and highlights how normalization of deviance contributed to each event.

National Institutes of Health.  August 11, 2022. RFA-HD-23-035.

Maternity care is increasingly being recognized as vulnerable to implicit biases and social inequities. This funding announcement aims to support initiatives that promote equity as a primary component of efforts to study preventable maternal harm in a variety of disadvantaged and ethnic populations. The application process is now closed.

Feibel C. Consider This. National Public Radio. August 3, 2022. 

Maternal complications risk the health of both mothers and babies, and a variety of circumstances create challenges to this complex care process. This article describes delays in care for a pregnant patient due to legal and policy concerns that threatened the life of the mother.
Ramsey L, McHugh SK, Simms-Ellis R, et al. J Patient Saf. 2022;18:e1203-e1210.
Patients and families can contribute unique insights into medical errors. This qualitative evidence review concluded that patients and families value involvement in patient safety incident investigations but highlight the importance of addressing the emotional aspects of care (e.g., timely apology, prioritizing trust and transparency). Healthcare staff perceived patient and family involvement in investigations to be important, but cited several barriers (e.g., staff turnover, fears of litigation) to effective investigations.

NIHCM Foundation. Washington DC: National Institute for Health Care Management. August 2, 2022.

Preventable maternal morbidity is an ongoing challenge in the United States. This infographic shares general data and statistics that demonstrate the presence of racial disparities in maternal care that are linked to structural racism. The resource highlights several avenues for improvement such as diversification of the perinatal staffing and increased access to telehealth.
Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:b2-b10.
The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.

Jones LA. The Philadelphia Inquirer. July 17, 2022. 

Racial disparities and inequities detract from safe maternal care. This feature article discusses the history of obstetric care in the United States and examines the roots of unsafe care for Black mothers that perpetuate in that community today.

Bryant A. UpToDate. June 28, 2022.

Implicit bias is progressively being discussed as a detractor to safe health care by fostering racial and ethnic inequities. This review examines the history of health inequities at the patient, provider, health care system, and cultural levels in obstetric and gynecologic care. It shares actions documented in the evidence base for application in health care to reduce the impact of implicit bias, with an eye toward maternal care
Howell EA, Sofaer S, Balbierz A, et al. Obstet Gynecol. 2022;139:1061-1069.
Health equity in maternal safety is a major patient safety goal. Researchers interviewed health care professionals, including frontline nurses and physicians, chief medical officers, and quality and safety officers, from high- and low-performing hospitals. Six themes emerged differentiating high and low performers: 1) senior leadership involved in day-to-day quality activities and dedicated to quality improvement, 2) a strong focus on standards and standardized care, 3) strong nurse-physician communication and teamwork, 4) adequate physician and nurse staffing and supervision, 5) sharing of performance data with nurses and other frontline clinicians, and 6) explicit awareness that racial and ethnic disparities exist and that racism and bias in the hospital can lead to differential treatment. PSNet offers a Patient Safety Primer and Curated Library on maternal safety.
Ramani S, Halpern TA, Akerman M, et al. Am J Obstet Gynecol. 2022;226:556.e1-556.e9.
Cesarean delivery can lead to adverse outcomes and is commonly used as a measure of obstetrical quality; however, these measures do not account for preexisting maternal and neonatal morbidities, which may increase risk for cesarean delivery. This article describes the development and testing of a new obstetrical quality measure that integrates cesarean delivery rates adjusted for preexisting high-risk maternal factors as well as maternal and neonatal morbidities. Among obstetricians in one large hospital, researchers found that this metric led to significantly different clinician rankings in terms of obstetrical quality (compared to rankings based on crude or adjusted cesarean delivery rates alone.) The authors suggest that this new metric can help identify opportunities for practice improvement among individual clinicians and institutions.
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.