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Ellis NT, Broaddus A. CNN. August 25, 2021. 

Maternal safety is an ongoing challenge worldwide. This news feature examines how the COVID pandemic has revealed disparities and implicit biases that impact the maternal care of black women. The stories shared highlight experiences of mothers with preventable pregnancy-related complications.

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.

Liese KL, Davis-Floyd R, Stewart K, et al. Anthropol Med. 2021;28(2):188-204.
This article draws on interviews and observations to explore medical iatrogenesis in obstetric care. The authors discuss how various factors – such as universal management plans, labor and delivery interventions, and informed consent – contribute to iatrogenic harm and worse perinatal outcomes for racial/ethnic minority patients.

Fourth Report of Session 2021–22. House of Commons Health Committee. London, England: The Stationery Office; July 6, 2021. Publication HC 19. 

High-profile failures motivate examination and change of existing services. This report builds on maternity care failures in National Health Service trusts to recommend needed changes in learning from failure to effectively support clinicians providing maternity care, provide patient-centered care to mothers and babies, and learn from untoward incidents to enhance care safety.
Small K, Sidebotham M, Gamble J, et al. Midwifery. 2021;102:103074.
Health information technologies intended to reduce patient harm may have unintended consequences (UC). Midwives describe the unintended consequences of central fetal monitoring technology. These consequences included potential loss of patient trust in the midwife, changes in clinical practice, and increased documentation during labor. The authors recommend reevaluation of use of central fetal monitoring due to potential UC without demonstrating improvements in maternal safety.
Kern-Goldberger AR, Kneifati-Hayek J, Fernandes Y, et al. Obstet Gynecol. 2021;138(2):229-235.
Patient misidentification errors can result in serious patient harm. The authors reviewed over 1.3 million electronic orders for inpatients at one New York hospital between 2016 and 2018 and found that wrong-patient order errors occurred more frequently on obstetric units than medical-surgical units. Medication errors were the largest source of order errors and commonly involved antibiotics and opioid and non-opioid analgesics.
Kruper A, Domeyer-Klenske A, Treat R, et al. J Surg Educ. 2021;78(3):1024-1034.
Physicians commonly experience adverse psychological outcomes after being involved in an adverse event. This mixed-methods study of health care providers in the Department of Obstetrics & Gynecology at one large academic hospital found that three-quarters of providers experienced symptoms of traumatic stress after involvement in an adverse event. Respondents reporting anxiety were more likely to be interested in peer-to-peer support programs, whereas those reporting symptoms of guilt preferred debriefing sessions.
Chung EH, Truong T, Jooste KR, et al. J Surg Educ. 2021;78(3):942-949.
Medical residents are frequently involved in difficult patient conversations, including error disclosure. This paper describes the development and implementation of a novel communications/didactic skills training program for OB/GYN residents. Immediately, and 3-months after training, residents indicated an improvement in their communication skills.
Rosen IEW, Shiekh RM, Mchome B, et al. Acta Obstet Gynecol Scand. 2021;100(4):704-714.
Improving maternal safety is an ongoing patient safety priority. This systematic review concluded that maternal near miss events are negatively associated with various aspects of quality of life. Women exposed to maternal near miss events were more likely to have overall lower quality of life, poorer mental and social health, and suffer negative economic consequences.

National Academies of Sciences, Engineering, and Medicine. June 7-8, 2021.

Maternal safety is challenged by clinical, equity, and social influences. This virtual event examined maternal health conditions in the United States to improve health system practice and performance for this population. Discussions addressed the need for better data collection, evidence-based practice, and social determinants knowledge integration to enhance the safety of care.

Weiser S. The New Yorker and Retro Report; 2021.

Disparities in maternal care have become apparent as a public health concern during the COVID-19 pandemic. This short film spotlights inequities and biases that Black mothers face, that reduce the safety of their care. Midwives are offered as a strategy for improving the safety of maternal care in this patient population.
Rivera-Chiauzzi E, Finney RE, Riggan KA, et al. J Patient Saf. 2021;Epub Apr 20.
Using a validated tool, this study found that nearly 19% of clinical and nonclinical healthcare workers in obstetrics and gynecology settings reported a second victim experience within the last 12 months.  Survey respondents who identified as a second victim reported significantly more psychological and physical distress, perceived inadequacy of institutional support, decreased professional self-efficacy, and increased turnover intentions. Prior research reported similar findings among nurses in obstetrics and gynecology.

Two separate patients undergoing urogynecologic procedures were discharged from the hospital with vaginal packing unintentionally left in the vagina. Both cases are representative of the challenges of identifying and preventing retained orifice packing, the critical role of clear handoff communication, and the need for organizational cultures which encourage health care providers to communicate and collaborate with each other to optimize patient safety.

McCarthy C, Meaney S, Rochford M, et al. J Patient Saf Risk Manag. 2021;26(2):56-63.
Labor and delivery wards are high-risk care environments. This mixed-methods study found that risk (characterized as harm, danger, hazards, or uncertainty) is a common experience in labor wards. Study participants commonly used debriefing as an important practice following a risk experience. The authors highlight the need for risk reduction strategies, staff support, and training to ensure staff wellbeing in stressful situations.
Lippke S, Derksen C, Keller FM, et al. Int J Environ Res Public Health. 2021;18(5):2616.
Communication is an essential component of safe patient care. This review of 71 studies found that communication training interventions in obstetrics can improve communication skills and behavior, particularly when combined with team training. The authors identified a lack of evidence regarding the effect of communication trainings on patient safety outcomes and suggest that future research should assess this relationship. Study findings underscore the need for adequate communication trainings to be provided to all staff and expectant mothers and their partners.
Haidari E, Main EK, Cui X, et al. J Perinatol. 2021;41(5):961-969.
High levels of healthcare worker (HCW) burnout may be associated with lower levels of patient safety and quality. In June 2020, three months into the COVID-19 pandemic, 288 maternity and neonatal HCWs were asked about their perspectives on well-being and patient safety. Two-thirds of respondents reported symptoms of burnout and only one-third reported adequate organizational support to meet these challenges. Organizations are encouraged to implement programs to reduce burnout and support HCW well-being.
Minehart RD, Bryant AS, Jackson J, et al. Obstet Gynecol Clin North Am. 2021;48(1):31-51.
Improving maternal safety and reducing disparities in maternal morbidity and mortality are national priorities. This article discusses inequities in maternal health outcomes and provision of care, factors involved in the relationship between race and health (e.g., racism, social status, health behaviors), and efforts at the national-, state-, and hospital-level to improve obstetric care and outcomes for Black mothers.
Boyle FM, Horey D, Siassakos D, et al. BJOG. 2020;128(4):696-703.
Patients, parents and caregivers play an important role in improving patient safety. Although parents have expressed interest in engaging in perinatal mortality review processes, this international survey of healthcare providers found that less than one-third of respondents (from various types of healthcare facilities) included parents in the review process at their institutions. The authors discuss the potential importance of parental involvement after perinatal mortality to improve care.
English M, Ogola M, Aluvaala J, et al. Arch Dis Child. 2021;106(4):326-332.
Health systems are encouraged to proactively identify patient safety risks. In the first of a two-part series, the authors draw on the  Systems Engineering Initiative for Patient Safety (SEIPS) framework  to discuss the strengths and challenge of a low-resource newborn unit from a systems perspective and SEIPS’ implications for patient safety.
Fransen AF, van de Ven J, Banga FR, et al. Cochrane Database Syst Rev. 2020;12:Cd011545.
Teamwork training simulation programs can improve communication and safety culture in obstetric teams. This systematic review found that simulation-based obstetric team training can improve team performance and may improve some maternal and perinatal outcomes. The authors note that future research should attempt to limit bias, improve precision, and pay attention to effect measurement at the patient outcome level.