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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.

This commentary presents two cases of near-miss wrong-patient order errors between mother-newborn pairs and discusses the unique threat the postpartum setting presents to electronic order safety. The article highlights opportunities for systems improvement.