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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.

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.

A healthy 53-year-old man presented for sexually transmitted infection (STI) screening after being informed by the health department that he had sexual intercourse with a male partner who was recently diagnosed with and treated for syphilis. He acknowledged having unprotected sex with male partners, reported no history of syphilis or Human Immunodeficiency Virus (HIV), and denied any penile lesions, discharge, or rash.

van Heesch G, Frenkel J, Kollen W, et al. Jt Comm J Qual Patient Saf. 2020;47(4):234-241.
Poor handoff communication can threaten patient safety. In this study set in the Netherlands, pediatric residents were asked to develop a contingency plan for patients received during handoffs and asked to recall information from that handoff five hours later. Results indicate that engaging in deliberate cognitive processing during handoffs resulted in better understanding of patients’ problems, which could contribute to improved patient safety.
Lagisetty P, Macleod C, Thomas J, et al. Pain. 2021;162(5):1379-1386.
Inappropriate prescribing of opioids is a major contributor to the ongoing opioid epidemic. This study involved simulated patients with chronic opioid use who called primary care clinics in need of a new provider because their previous physician had retired or stopped prescribing opioids. Findings indicate that primary care providers were generally unwilling to prescribe opioids to patients whose histories are suggestive of misuse, which may raise access to care concerns and cause potential unintended harm for some patients.  

Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 5, 2021. Report No. 20-01521-48.

 

This investigation examined care coordination, screening and other factors that contributed to a patient death by suicide shortly after discharge from a Veteran’s Hospital. Event reporting, disclosure and evaluation gaps were identified as process weaknesses to be addressed. 

AHA Team Training.
 

The COVID-19 crisis requires cooperation and coordination of organizations and providers to address the persistent challenges presented by the pandemic. This on-demand video collection reinforces core TeamSTEPPS; methods that enhance clinician teamwork and communication skills to manage care safety during times of crisis. 
Arshad SA, Ferguson DM, Garcia EI, et al. J Surg Res. 2021;257:455-461.
Engaging patients and families is an important strategy in ensuring safe health care delivery. In this prospective, observational study, use of a parent-centered script did not improve parent engagement during the preinduction checklist and resulted in an expected decline in checklist adherence.  
Erkelens DC, Rutten FH, Wouters LT, et al. J Patient Saf. 2022;18(1):40-45.
Delays in diagnosis and treatment during after-hours care pose serious threats to patient safety. This case-control study compared missed acute coronary syndrome (ACS) cases to other cases with chest discomfort occurring during out-of-hours services in primary care. Predictors of missed ACS included the use of cardiovascular medication, non-retrosternal chest pain, and consultation of the supervising general practitioner.   
Bhat A, Mahajan V, Wolfe N. J Clin Neurosci. 2021;85(Mar):27-35.
Misdiagnosis, variation in treatment of stroke and gaps in secondary prevention in young patients can result in adverse outcomes. This article discusses the possible causes of implicit bias in stroke care in this population, the effects of bias on patient outcomes, and interventions to circumvent implicit bias.  
Lam BD, Bourgeois FC, Dong ZJ, et al. J Am Med Inform Assoc. 2021;28(4):685-694.
Providing patients access to their medical records can improve patient engagement and error identification. A survey of patients and families found that about half of adult patients and pediatric families who perceived a serious mistake in their ambulatory care notes reported it, but identified several barriers to reporting (e.g. no clear reporting mechanism, lack of perceived support).  

After a breast mass was identified by a physician assistant during a routine visit, a 60-year-old woman received a diagnostic mammogram and ultrasound. The radiology assessment was challenging due to dense breast tissue and ultimately interpreted as “probably benign” findings. When the patient returned for follow-up 5 months later, the mass had increased in size and she was referred for a biopsy.

Mangrum R, Stewart MD, Gifford DR, et al. J Am Med Dir Assoc. 2020;21(11):1587-1591.e2.
Building upon earlier work, the authors engaged a technical expert panel to reach consensus on a definition for omissions of care in nursing homes. The article details the terms and concepts included in (and excluded from) the proposed definition, provides examples of omissions of care, intended uses (e.g., to guide quality improvement activities or training and education), and describes the implications of the definition for clinical practice, policy, and research.  

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.   
Hendy J, Tucker DA. J Bus Ethics. 2020;2021;172:691–706.
Using the events at the United Kingdom’s Mid Staffordshire Trust hospital as a case study, the authors discuss the impact of ‘collective denial’ on organizational processes and safety culture. The authors suggest that safeguards allowing for self-reflection and correction be implemented early in the safety reporting process, and that employees be granted power to speak up about safety concerns.
Abdelhadi N, Drach‐Zahavy A, Srulovici E. J Adv Nurs. 2020;Epub Apr 13.
This qualitative study conducted focus groups with 28 registered nurses working in different hospital settings to explore perspectives regarding decision-making and personal or contextual attributes leading to missed nursing care.  Three themes emerged based on the analysis: missed nursing care can result due to scarce resources or nurses’ agency, differences in thinking based on routine or novel situations, and situational factors triggering fluctuations in their awareness (such as difficult patients or the presence of family). The authors suggest that organizational training programs should encourage nurses to identify barriers and facilitators of missed nursing care and approaches to overcome these factors.