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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.

Sullivant SA, Brookstein D, Camerer M, et al. Jt Comm J Qual Patient Saf. 2021;47(8):496-502.
Improving screening for suicidal ideation is an important patient safety priority. This article describes the implementation and evaluation of a hospital-wide program to identify teenagers at elevated risk for suicide and to connect them with services. During the first year of implementation, over 138,000 screenings were completed and 6.8% of screens were positive for elevated risk.
Chang T-P, Bery AK, Wang Z, et al. Diagnosis (Berl). 2021;Epub Jun 20.
A missed or delayed diagnosis of stroke increases the risk of permanent disability or death. This retrospective study compared rates of misdiagnosed stroke in patients presenting to general care or specialty care who were initially diagnosed with “benign dizziness”. Patients with dizziness who presented to general care were more likely to be misdiagnosed than those presenting to specialty care. Interventions to improve stroke diagnosis in emergency departments may also be successful in general care clinics.

Allen LV, Jr. Int J Pharm Compd. 2021;25:131-139; 222-229.

Intravenous admixture compounding is a complex activity that harbors risks for patients and health care staff.  This two-part series reviews the types of errors that compromise the safety of compounding practices, steps in the process where they occur and prevention tactics.
Pulia M, Wolf I, Schulz L, et al. West J Emerg Med. 2020;21(5):1283-1286.
Antimicrobial stewardship is one strategy to improve antibiotic use to reduce hospital-acquired infections. In this editorial, the authors discuss negative effects of COVID-19 on antimicrobial resistance and antibiotic stewardship in the emergency department (ED) and approaches for optimizing ED stewardship during the pandemic.  
Stark N, Kerrissey M, Grade M, et al. West J Emerg Med. 2020;21(5):1095-1101.
This article describes the development and implementation of a digital tool to centralize and standardize COVID-19-related resources for use in the emergency department (ED). Clinician feedback suggests confirms that the tool has affected their management of COVID-19 patients. The tool was found to be easily adaptable to accommodate rapidly evolving guidance and enable organizational capacity for improvisation and resiliency.  
Harper PG, Schafer KM, Van Riper K, et al. J Am Pharm Assoc (2003). 2020;Epub Sept 14.
This article a systematic team-based care approach to medication reconciliation implemented in four family medicine residency clinics. After implementation, there was a significant increase in the number of visits with physician-documented medication reconciliation and this increase was sustained one year later.
Foster CB, Ackerman K, Hupertz V, et al. Pediatrics. 2020;146(4):e20192057.
This article describes the implementation and results of catheter-associated urinary tract infection (CAUTI) prevention efforts by a large network of children’s hospitals between 2011 and 2017. Prevention efforts included catheter insertion and maintenance bundles. After implementation of the bundles, CAUTI rates across the network decreased by 61.6%.
Choi GYS, Wan WTP, Chan AKM, et al. Br J Anaesth. 2020;125(2):e236-e239.
This study used high-fidelity clinical simulation to replicate admission, including tracheal intubation, of a patient with suspected or known COVID-19 infection to assess the ability of healthcare teams to effectively use personal protective equipment (PPE), the use of intubation protocols and infection control guidelines. Based on observations of 11 simulations involving 44 participants, several infection control-related workflow problems and safety threats were identified, including issues with PPE donning and doffing, advance preparation of intubation and ventilation strategies, environmental protection measures, communication difficulties, and accessibility of key drugs and equipment. These findings resulted in guideline changes, modifications to the environment and implementation of workflow modifications to improve ability of staff to adhere to infection control guidelines.
A 52-year old women presented to the emergency department with a necrotizing soft tissue infection (necrotizing fasciitis) after undergoing cosmetic abdominoplasty (‘tummy tuck’) elsewhere. A lack of communication and disputes between the Emergency Medicine, Emergency General Surgery and Plastic Surgery teams about what service was responsible for the patient’s care led to delays in treatment. These delays allowed the infection to progress, ultimately requiring excision of a large area of skin and soft tissue.
Malterud K, Aamland A, Fosse A. Scand J Prim Health Care. 2020;38.
Using qualitative analysis, this study explored the experiences of general practitioners in Norway with horizontal task shifting (defined as tasks shifted between equivalent professionals, such as hospital specialists and other specialists) and whether task shifting increased patient safety risks. The study identified several types of adverse events associated with horizontal task shifting, such as delays in diagnosis, overdiagnosis, and reduced access to care.
Dexter F, Parra MC, Brown JR, et al. Anesth Analg. 2020;131(1):37-42.
The authors describe eight empirical recommendations for optimizing infection control and operating room (OR) management during the COVID-19 pandemic. Recommendations address (1) hand hygiene, (2) environmental cleaning, (3) patient decolonization, (4) vascular care, (5) surveillance of pathogen transmission, (6) efficient use of personal protective equipment (7) OR scheduling, and (8) postoperative recovery settings.
Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.
Maternal care during and after childbirth is at risk for never events including retained foreign objects. This analysis of a sentinel event involving a retained surgical tampon after childbirth discusses communication, fatigue, and process factors that contributed to the incident. The report suggests improved handoffs as one improvement strategy.
Feldman SS, Brazil V, Zengul FD, et al, eds. Health Syst (Basingstoke). 2019;8(3):153-227.
Informatics and simulation are core contributors to the reduction of medical system failures. This special issue examined how these ideas merge to create opportunities for improvement. Care management and adverse incident prevention are two areas of focus explored in the issue.   
A man with a history of T6 paraplegia came to the emergency department with delirium, hypotension, and fever. Laboratory results revealed a high white blood cell count and mild elevation of bilirubin and liver enzymes. A stat abdominal CT showed a mildly thickened gallbladder. The patient was admitted to the intensive care unit with a provisional diagnosis of septic shock and treated with broad-spectrum antibiotics and intravenous fluids. He was transferred to the medical ward on hospital day 2, where the receiving hospitalist realized the diagnosis was still unclear.
A woman with a history of prior spine surgery presented to the emergency department with progressive low back pain. An MRI scan of T11–S1 showed lumbar degenerative joint disease and a small L5–S1 disc herniation. She was referred for physical therapy and prescribed muscle relaxant, non-steroidal anti-inflammatories, and pain relievers. Ten days later, she presented to a community hospital with fever, inability to walk, and numbness from the waist down. Her white blood cell count was greater than 30,000 and she was found to be in acute renal and liver failure.