The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Obstetric and gynecologic (OB/GYN) physicians are frequently involved in malpractice lawsuits, some of which result in catastrophic payouts. This study categorized malpractice claims involving OB/GYN trainees (students, residents, and fellows) between 1986 and 2020. Cases are categorized by type of injury, patient outcome, category of error, outcome of lawsuit, and amount of settlement.
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...
Macrae C, Draycott T. Safety Sci. 2019;117:490-500.
Simulation training can enhance teamwork, identify latent problems, and contribute to improved patient outcomes. This commentary explores the value of frontline obstetric simulation to develop high reliability. The authors discuss relational rehearsal, system structuring, and practice elaboration as elements of a successful simulation-focused organizational learning initiative.
Ansari SP, Rayfield ME, Wallis VA, et al. J Patient Saf. 2020;16:e359-e366.
This study describes a multidisciplinary human factors training intervention for labor and delivery care that included communication training and simulation work. Researchers found that safety culture improved compared to preintervention scores.
Greer JA, Haischer-Rollo G, Delorey D, et al. Cureus. 2019;11:e4096.
This pre–post study examined the effect of team training on an emergency response team's performance in a perinatal emergency simulation. Following the training, performance in the simulation identified more latent safety threats and adherence to a safety checklist increased. The authors suggest that team training can enhance maternal safety.
Sherman JP, Hedli LC, Kristensen-Cabrera AI, et al. Am J Perinatol. 2020;37:638-646.
This direct observation study examined maternal and neonatal care at 10 labor and delivery units. Investigators uncovered three environmental needs that impact safety: rapid access to blood products, space for neonatal resuscitation, and organization and availability of equipment and supplies. They conclude that applying design thinking to physical space could improve maternal and neonatal safety.
Lefebvre G, Calder LA, De Gorter R, et al. J Obstet Gynaecol Can. 2019;41:653-659.
Obstetrics is a high-risk practice that concurrently manages the safety of mothers and newborns. This commentary describes the importance of standardization, checklist use, auditing and feedback, peer coaching, and interdisciplinary communication as strategies to reduce risks. The discussion spotlights the need for national guidelines and definitions to reduce variation in auditing and training activities and calls for heightened engagement of health care professionals to improve the safety and quality of obstetric care in Canada. An Annual Perspective reviewed work on improving maternal safety.
Ogunyemi D, Hage N, Kim SK, et al. Jt Comm J Qual Patient Saf. 2019;45:423-430.
The rise in maternal morbidity and mortality is one of the most pressing patient safety issues in the United States. Formal debriefing after adverse events is an important method for analyzing and improving safety. In this study, an academic hospital adopted a systems-based morbidity and mortality conference model to review cases of serious maternal harm and implemented several safety measures (including teamwork training) to address issues that were identified through structured review.
Maternal mortality is a sentinel event that affects mothers and families across a wide range of socioeconomic characteristics. This commentary explores how data collection gaps, medical errors, ineffective treatments, and care coordination weaknesses contribute to preventable maternal death. The author highlights efforts to improve safety in maternity care such as best practice bundles to ensure teams and clinicians are prepared for certain complications.
Romijn A, Ravelli A, de Bruijne MC, et al. BJOG. 2019;126:907-914.
This cluster-randomized trial examined whether a team training intervention would improve perinatal and maternal outcomes for singleton births without congenital abnormalities, on or after 32 weeks gestation. Researchers found no significant change in incidence of adverse outcomes, suggesting that simulation-based training alone is not sufficient to optimize perinatal safety.
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.
Park CS, Stojiljkovic L, Milicic B, et al. Simul Healthc. 2014;9:85-93.
This educational study found that anesthesiology residents were more likely to initiate an airway technique for which they had received simulation training, even if another technique (for which they received didactic training) would have been more appropriate. This finding demonstrates how training may inadvertently introduce cognitive bias.
Pettker CM, Thung SF, Raab CA, et al. Am J Obstet Gynecol. 2011;204:216.e1-6.
A multifaceted patient safety program resulted in a sustained improvement in safety culture in an academic obstetrics unit. The program had previously been shown to reduce the incidence of preventable adverse events.
Grunebaum A, Chervenak F, Skupski D. Am J Obstet Gynecol. 2011;204:97-105.
Implementing a comprehensive safety program, which included teamwork training, additional staffing and reduction of work hours, electronic medical records, and a dedicated patient safety nurse, was associated with a sharp reduction in malpractice lawsuits and sentinel events at an academic hospital.
Pronovost PJ, Holzmueller CG, Ennen CS, et al. Am J Obstet Gynecol. 2011;204:5-10.
The first in a new patient safety series, this article reviews efforts to improve safety in obstetrics and gynecology, provides a framework for research, and offers suggestions to enhance safety in the specialty.
This case report discusses how an error with no lasting patient harm served as a catalyst for organizational efforts on process improvement, protocol review, and safeguard enhancement to ensure safe delivery of epidural analgesia.
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