Han D, Khadka A, McConnell M, et al. JAMA Netw Open. 2020;3:e2024589.
Unexpected death or serious disability of a newborn is considered a never event. A cross-sectional analysis including over 5 million births between 2011 and 2017 in the United States found unexpected newborn death was associated with a significant increase in use of procedures to avert or mitigate fetal distress and newborn complications (e.g., cesarean delivery, antibiotic use for suspected sepsis). These findings could reflect increased caution among clinicals or indicate more proactive attempts to identify and address potential complications.
Kozhimannil KB. Health Aff (Millwood). 2018;37:1901-1904.
Maternal harm is a sentinel event that is gaining increased attention in both policy and clinical environments. In this commentary, the author relates her family history of maternal morbidity and mortality and advocates for enhancements in collecting data on maternal health outcomes, access to care, understanding of racial disparities, accountability, and listening to patients and families who have been impacted by unsafe maternal care.
Schnapp BH, Sun JE, Kim JL, et al. Diagnosis (Berl). 2018;5:135-142.
In 2015, the National Academy of Medicine called for renewed focus on reducing diagnostic error. Among patients admitted to the hospital shortly after discharge home from the emergency department, researchers found that 19% of cases involved a cognitive error, such as faulty information processing or inaccurate data verification, which may contribute to diagnostic errors.
Law AC, Roche S, Reichheld A, et al. Jt Comm J Qual Patient Saf. 2019;45:276-284.
Emotional and psychological harm are understudied but common preventable adverse events. Overt disrespect from health care providers and the lasting psychological impact of safety hazards both contribute to emotional harm. This large, prospective study explored emotional harm among 1559 family members of intensive care unit patients at a hospital in Boston, Massachusetts. About 22% of family members reported inadequate respect toward either themselves or the patient, and more than half of respondents perceived a lack of control over their loved one's care. Inadequate respect and lack of control were strongly correlated with overall satisfaction with care. A WebM&M commentary discussed the utility of family-centered care to preventing harm in the intensive care unit.
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