The PSNet Collection

Maternal Safety

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.

Unwell Women: Misdiagnosis and Myth in a Man-Made World.

Cleghorn E. New York, NY: Dutton; 2021. ISBN: 9780593182956.

Women have been affected by implicit bias that undermines the safety of their care and trust in the medical system. This book shares the history anchoring the mindsets driving ineffective care for women and a discussion of the author’s long-term lupus misdiagnosis.

How medical jargon can make COVID health disparities even worse.

Kritz F. Shots. National Public Radio; May 24, 2021.

Health literacy efforts address challenges related to both language and effective communication tactics. This story discussed how lack of language and information clarity reduced patient education effectiveness during the pandemic and highlights several efforts to address them including information product translation services.

Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals.

McHugh MD, Aiken LH, Sloane DM, et al. The Lancet. 2021;397(10288):1905-1913.

While research shows that better nurse staffing ratios are associated with improved patient outcomes, policies setting minimum nurse-to-patient ratios in hospitals are rarely implemented. In 2016, select Queensland (Australia) hospitals implemented minimum nurse staffing ratios. Compared to hospitals that did not implement minimum nurse staffing ratios, length of stay, mortality, and readmission rates were significantly lower in intervention hospitals, providing evidence, once again, that minimum staffing ratios can improve patient outcomes.

Cancer diagnoses delayed among prisoners in Washington state.

Medscape Medical News. May 12, 2021.

Delays and mistakes in health care for distinct patient populations hold improvement lessons for the broader system. This news story highlights problems in correctional system cancer diagnoses and treatment that may indicate other types of prison care delivery problems.

What does safety in mental healthcare transitions mean for service users and other stakeholder groups: an open-ended questionnaire study.

Tyler N, Wright N, Panagioti M, et al. Health Expect. 2021;24(Suppl 1):185-194.

Transitions of care represent a vulnerable time for patients. This survey found that safety in mental healthcare transitions (hospital to community) is perceived differently by patients, families, and healthcare professionals. While clinical indicators (e.g., suicide, self-harm, and risk of adverse drug events) are important, patients and families also highlighted the social elements of transitional safety (e.g., loneliness, emotional readiness for change).

The COVID-19 pandemic and dentistry: parts 1 and 2.

Coulthard P, Thomson P, Dave M, et al. Br Dent J. 2020;229:743-747; 801-805.

The COVID-19 pandemic suspended routine dental care. This two-part series discusses the clinical challenges facing the provision of routine dental care during the pandemic (Part 1) and the medical, legal, and economic consequences of withholding or delaying dental care (Part 2).

The Life and Death of Elizabeth Dixon: A Catalyst for Change.

Kirkup B. London, England: Crown Copyright; 2020. ISBN 9781528622714.

Missed diagnosis of a dangerous condition in utero, treatment errors, lack of response to concerns raised, and inadequate clinician expertise were among the contributing factors identified in this analysis of the death of a special needs infant at home. The 12 recommendations stemming from the investigation include improvements in disclosure support, clinician communication across facilities, and assignment of accountability when false and misleading statements are made during investigations.

‘You’re going to release him when he was hurting himself?’

Dahlberg B. Kaiser Health News. September 29, 2020.

This story discusses failures related emergency psychiatric assessment, including premature discharge, implicit bias, patient management discontinuity and inappropriate physical restraint that contributed to the death of a patient at risk for suicide.

The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul.

de Bienassis K, Llena-Nozal A, Klazinga N for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 121.

Adverse events in long term care facilities are acerbated due to staffing, training and financial challenges. This report examined the costs of avoidable problems in long term care and suggests prevention strategies that center on workforce skill development and safety culture improvement.

High-Performance Work Systems in Health Care Management: Parts 1-5.

Garman AN, McAlearney AS, Harrison MI, et al. Health Care Manag Rev. 2011-2020.

In this continuing series, high-performance work practices are explored and defined through literature review, case analysis, and research. The authors summarize findings and discuss how best practices can influence quality, safety, and efficiency outcomes. Topics covered include speaking up, central line infection prevention, and business case development.

Sent home to die.

Waldman A, Kaplan J. ProPublica. 2020.

Hospitals have been deeply challenged to provide effective care during the COVID crisis. This article discusses how rationing and ineffective protection for families and patients may have contributed to preventable death and the spread of the virus in families due to unnecessary referrals of patients to home care and hospice.

Doctors turned my sister away; less than two years later she died of cervical cancer.

Harvey-Jenner C. Cosmopolitan. August 27, 2020.

Implicit biases are known to impact effective diagnosis. This story highlights how dismissed concerns resulted in a delay in cancer diagnosis that contributed to the death of a young woman.

Hastened death due to disease burden and distress that has not received timely, quality palliative care is a medical error.

Gallagher R, Passmore MJ, Baldwin C. Med Hypotheses. 2020;142:109727.

The authors of this article suggest that offering palliative care services earlier should be considered a patient safety issue. They highlight three cases in which patients in Canada requested medical assistance in dying (MAiD). The patients in two of the cases were never offered palliative care services, and this could be considered a medical error – had they been offered palliative care services, they may have changed their mind about MAiD, as did the patient in the third case study.

Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center.

Office of the Inspector General. Washington, DC: Department of Veterans Affairs; July 28, 2020. Report Number 19-07507-214.

Patient suicide is a never event. This report analyzes the death of a veteran after presenting at an emergency room with suicidal ideation. The analysis found lack of both suicide prevention policy adherence and appropriate assessment, as well as a lack concern for the patient’s condition contributed to the failure.

Fear of Covid-19 leads other patients to decline critical treatment.

Hafner K. New York Times. 2020;May 25.

The uncertainties surrounding coronavirus transmission and treatment are causing patients with known conditions to forgo needed medical care. This article outlines how COVID-19 fear and anxiety are primary contributing factors in patient decisions to delay transplants and other necessary treatments.

As COVID-19 bears down, doctors confront difficult choices on elective surgeries.

Alesse L, Dukakis A, Tatum S, Mosk M. ABC News. March 20, 2020.

Delays in elective surgery and other procedures have the potential to lessen safe patient care. This news story describes the decision-making dilemma for physicians to limit patient access to care during the COVID-19 pandemic. Their concern is that the delays have the potential to result in diagnostic and treatment service deviations that could result in harm.

A 25-year-old teacher died after waiting hours at the ER. She's not the only one who saw delays.

Linnane R, Diedrich J. Milwaukee Journal Sentinel. February 25, 2020.

Delays in emergency room (ER) triage and assessment contribute to wide range of failures that degrade patient safety. This news story highlights the findings of a government report highlighting overcrowding and production pressures as factors resulting in the death of a patient waiting for care who initially presented at the ER with symptoms of heart attack.

Investigation into Detection of Retained Vaginal Swabs and Tampons Following Childbirth.

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.

What is an ethically informed approach to managing patient safety risk during discharge planning?

West JC. AMA J Ethics. 2020;22(!1):e919-e923.

Patient safety is a concern throughout the entire process of care from admission to discharge. This article highlights the role of risk managers to assure that patients return to a home environment that can enable their safe recovery whether the discharge is advised or not.

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