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Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization, teamwork, unit-based safety initiatives, and trigger tools.

Azam I, Gray D, Bonnett D et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2021. AHRQ Publication No. 21-0012.
The National Healthcare Quality and Disparities Reports review analysis specific to tracking patient safety challenges and improvements across ambulatory, home health, hospital, and nursing home environments. The most recent update documented improvements in approximately half of the patient safety measures tracked. This set of tools includes summaries drawn from the reports for use in presentations to enhance distribution and application of the data.
Kapoor A, Field T, Handler S, et al. JAMA Intern Med. 2019;179(9):1254-1261.
Transitions from hospitals to long-term care facilities are associated with safety hazards. This prospective cohort study identified adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included 762 discharges during the study period. Investigators found that adverse events occurred after approximately half of discharges. Common adverse events included falls, pressure ulcers, health care–associated infections, and adverse drug events. Most adverse events were deemed preventable or ameliorable. The authors conclude that improved communication and coordination between discharging hospitals and receiving long term-care facilities are urgently needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that may contribute to adverse events.
Sankaran R, Sukul D, Nuliyalu U, et al. BMJ (Clinical research ed.). 2019;366:l4109.
The Centers for Medicare and Medicaid Services impose financial penalties on hospitals whose Medicare patients experience higher rates of hospital-acquired conditions (HACs) like urinary tract infections and pneumonia. Hospitals caring for more patients with low socioeconomic status receive more penalties under this program than hospitals caring for wealthier populations. Investigators attempted to assess whether hospitals penalized under the program reduced HAC rates. They found that penalized hospitals did not have lower HAC rates or improve other measures of clinical quality. This finding raises questions about whether financial penalties effectively enhance patient safety. By contrast, quality improvement collaboratives like Partnership for Patients have markedly reduced HACs. A PSNet interview with former AHRQ director Andrew Bindman explored strategies for reducing health care–acquired harm in the hospital and ambulatory settings.
Woeltje KF, Olenski LK, Donatelli M, et al. Joint Commission journal on quality and patient safety. 2019;45:480-486.
The Eisenberg Award honors individuals and organizations who have made important contributions to patient safety and quality improvement. Spotlighting the accomplishments of the 2018 recipients, this special issue includes an interview with Dr. Brent C. James, as well as articles on programs at The Society of Thoracic Surgeons and BJC HealthCare.
Abusalem S, Polivka B, Coty M-B, et al. J Patient Saf. 2021;17(4):299-304.
Prior research on the relationship between culture of safety and adverse events has produced conflicting results. Using culture of safety survey data from five long-term care facilities, researchers found an association between improved safety culture scores and a decreased risk of certain adverse events.
Smith PK, Amster A. Joint Commission journal on quality and patient safety. 2019;45:304-314.
This commentary describes how one health system developed and utilized an inpatient safety composite measure to track hospital-level performance on a select set of adverse events. The authors found that the tool successfully quantified improvement over time and suggest it can be used by other hospitals and health systems.
Haukland EC, Mevik K, von Plessen C, et al. BMJ open quality. 2019;8:e000377.
This study used the Global Trigger Tool to review all inpatient deaths in a Norwegian hospital for evidence of adverse events. Adverse events occurred in more than a quarter of patients who died in the hospital, a significantly higher rate compared to a control group of hospitalized patients who survived. The study did not assess the preventability of deaths; prior studies have consistently found that about 5% in-hospital deaths are likely preventable.
An elderly woman with a history of dementia, chronic obstructive pulmonary disease, hypertension, and congestive heart failure (CHF) was brought to the emergency department and found to meet criteria for sepsis. Due to her CHF, she was admitted to a unit with telemetry monitoring, which at this institution was performed remotely. When the nurse came to check the patient's vital signs several hours later, she found the patient to be unresponsive and apneic, with no palpable pulse. A Code Blue was called, but the patient died.
Rau J. Kaiser Health News. March 1, 2019.
Financial incentives may encourage adoption of practice improvements that enhance safety. This news article reports on the increase in United States hospitals that have had Medicare payments withheld due to high rates of hospital-acquired conditions. The article is accompanied by a state-level tally of individual hospitals penalized.
Sunshine JE, Meo N, Kassebaum NJ, et al. JAMA network open. 2019;2:e187041.
The seminal report, To Err Is Human, famously estimated that 44,000 to 98,000 deaths per year in the United States were due to medical errors. Although certain patient harms thought to be unavoidable at the time of the report's publication in 1999 are now considered completely preventable, experts suggest that progress in the field of patient safety has been slower than initially anticipated and that areas such as ambulatory safety and diagnostic error represent emerging priorities. In this cohort study, researchers used data from 1990 through 2016 on mortality related to the adverse effects of medical treatment (AEMT) from the Global Burden of Diseases, Injuries, and Risk Factors 2016 study. For the study period, researchers attribute 123,603 deaths to AEMT. The number of such deaths increased, but the US age-standardized mortality rate for deaths due to AEMT decreased by 21% between 1990 and 2016. The authors noted similar AEMT mortality rates for men as compared to women, significantly increased AEMT mortality rates for those age 70 and older, and geographic variation with regard to age-standardized AEMT mortality rates. An Annual Perspective discussed challenges associated with measuring and responding to deaths associated with medical errors.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2018. Report No. OEI-06-14-00530.
Frail populations cared for in long-term care facilities are at high risk for adverse events. This report from the Office of the Inspector General (OIG) analyzed Medicare data from 2008 to 2016 to determine the prevalence of adverse events in long-term care facilities and the resultant harm to residents. Nearly half of patients experienced adverse events or temporary harm events. A significant proportion of these events were considered serious, meaning that they led to prolonged stay, transfer to acute care, provision of life-saving intervention, or resulted in permanent harm or death. More than half of these events were found to be preventable and were attributed either to error or substandard care. The OIG recommends that patient safety efforts undertaken by the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services specifically address long-term care facilities. A past WebM&M commentary discussed safety and quality of long-term care.
Anand P, Kranker K, Chen AY. Health services research. 2019;54:86-96.
Pressure ulcers, surgical site infections, and other hospital-acquired conditions are common preventable harms in hospitals. In 2008, the Centers for Medicare and Medicaid Services stopped paying for care related to preventable hospital-acquired conditions. Investigators estimated the financial cost of those conditions using a national database. Added cost varied from $32,000 for a surgical site infection to $9000 for a hospital-acquired urinary tract infection. Certain conditions increased the total cost of the hospital stay by more than 50%. Patients with preventable hospital-acquired conditions were more likely to be readmitted within 90 days. A WebM&M commentary explored the cascade of events that can lead to a hospital-acquired bloodstream infection and how to prevent them.
Cooper J, Williams H, Hibbert P, et al. Bulletin of the World Health Organization. 2018;96:498-505.
The World Health Organization International Classification for Patient Safety enables measurement of safety incident severity. In this study, researchers describe how they adapted the system to primary care. Their harm severity classification emphasizes psychological harm, hospitalizations, near misses, and uncertain outcomes in addition to traditional markers of harm.
Agency for Healthcare Research and Quality; AHRQ.
Health literacy is important for effective care communications and safe medication use. This toolkit provides resources associated with medication therapy management and patient health literacy. Materials include health literacy assessments and guidance for prescription medicine instructions. A past PSNet perspective discussed the role of health literacy in patient safety.
Rafter N, Hickey A, Conroy RM, et al. BMJ Qual Saf. 2017;26(2):111-119.
In this retrospective study, researchers sought to understand the frequency of adverse events across Irish hospitals in the context of recent financial constraints. Review of 1574 records from inpatient admissions revealed that adverse events occurred in approximately 12% of cases and contributed to significantly increased costs.

London, UK: Parliamentary and Health Service Ombudsman; July 18, 2016. ISBN: 9781474135764.

The National Health Service (NHS) has a history of sharing analyses of problems in its system. Summarizing an NHS investigation into the death of a 3-year-old boy, this report highlights the need to improve organizational culture, complaint follow-up, and transparency to reduce opportunities for similar incidents.
Center for Health Design.
Elements of the health care work environment can affect the care delivery. This website highlights design considerations for health care facilities that can help reduce noise, falls, and hospital-acquired infections. The collection includes an assessment and interactive tools to test ideas for improvement.
Coomer NM, Kandilov AMG. American journal of infection control. 2016;44:1326-1334.
Hospital-acquired conditions (HACs) are a costly source of patient harms. Prior analyses have suggested that HACs lead to nearly $150 million per year in excess Medicare costs. Examining the financial burdens placed on Medicare patients who develop an HAC, this study found that these patients are liable for increased deductibles, copayments, and coinsurance, resulting in approximately $20.5 million per year in added cost burdens.