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The Uneven Burden of Maternal Mortality in the U.S.

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NIHCM Foundation. Washington DC: National Institute for Health Care Management. August 2, 2022.

Preventable maternal morbidity is an ongoing challenge in the United States. This infographic shares general data and statistics that demonstrate the presence of racial disparities in maternal care that are linked to structural racism. The resource highlights several avenues for improvement such as diversification of the perinatal staffing and increased access to telehealth.

Society for Maternal-Fetal Medicine Special Statement: Cognitive bias and medical error in obstetrics-challenges and opportunities.

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Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:B2-B10.

The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.

The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science.

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Bajaj K, de Roche A, Goffman D. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. AHRQ Publication No. 20(21)-0040-6-EF.

Maternal safety is threatened by systemic biases, care complexities, and diagnostic issues. This issue brief explores the role of diagnostic error in maternal morbidity and mortality, the preventability of common problems such as maternal hemorrhage, and the importance of multidisciplinary efforts to realize improvement. The brief focuses on events occurring during childbirth and up to a week postpartum.

Curated Libraries

Maternal Safety

Streamlining care in crisis: rapid creation and implementation of a digital support tool for COVID-19.

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Stark N, Kerrissey M, Grade M, et al. West J Emerg Med. 2020;21:1095-1101.

This article describes the development and implementation of a digital tool to centralize and standardize COVID-19-related resources for use in the emergency department (ED). Clinician feedback suggests confirms that the tool has affected their management of COVID-19 patients. The tool was found to be easily adaptable to accommodate rapidly evolving guidance and enable organizational capacity for improvisation and resiliency.

Improving Diagnosis and Treatment of Maternal Sepsis.

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Stanford, CA; California Maternal Quality Care Collaborative: January 22, 2020.

This toolkit focuses on identification of, and rapid response to, sepsis in obstetric patients. It includes screening, evaluation and monitoring, and antibiotic use recommendations for maternal sepsis patient.

Patient Safety.

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Halamek LP, ed. Semin Perinatol. 2019;43(8):151172-151182.

The neonatal intensive care unit (NICU) is a complex environment that serves a vulnerable population at increased risk for harm should errors occur. This special issue draws from a multidisciplinary set of authors to explore patient safety issues arising in the NICU. Included in the issue are articles examining topic such as video assessment, diagnostic error, and human factors engineering in the NICU.

How to reduce maternal mortality rates in the United States.

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Livingston E, Howell EA. JAMA Clin Rev. April 2, 2019.

Maternal mortality in the United States is gaining increased attention as a patient safety concern. This podcast discusses conditions known to challenge maternal safety, the high incidence of preventable harm in this population, and care bundles as an improvement strategy. A recent Annual Perspective summarized national initiatives to improve safety in maternity care.

Patient Safety.

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Todd DW, Bennett JD, eds. Oral Maxillofac Surg Clin North Am. 2017;29:121-244.

Articles in this special issue provide insights into how human error can affect the safety of oral and maxillofacial surgery, a primarily ambulatory environment. The authors cover topics such as simulation training, wrong-site surgery, and the safety of office-based anesthesia.

Reductions in sepsis mortality and costs after design and implementation of a nurse-based early recognition and response program.

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Jones SL, Ashton CM, Kiehne L, et al. Jt Comm J Qual Patient Saf. 2015;41:483-91.

A protocolized early warning system to improve sepsis recognition and management was associated with a decrease in sepsis-related inpatient mortality. The protocol emphasized early recognition by nurses and escalation of care by a nurse practitioner when indicated. An AHRQ WebM&M commentary describes common errors in the early management of sepsis.

Classifying errors in preventable and potentially preventable trauma deaths: a 9-year review using the Joint Commission's standardized methodology.

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Vioque SM, Kim PK, McMaster J, et al. Am J Surg. 2014;208:187-194.

Approximately 1 in 13 deaths of patients with major trauma were considered preventable or potentially preventable in this retrospective review from an urban trauma center. Diagnostic errors during the initial trauma assessment were a frequent contributor to preventable harm.

An infection, unnoticed, turns unstoppable.

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Dwyer J. New York Times. July 11, 2012:A15.

This newspaper article reports on gaps in communication and a missed sepsis diagnosis that led to a patient's death.

Patient Safety in the Context of Perinatal, Neonatal, and Pediatric Care.

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Eunice Kennedy Shriver National Institute of Child Health and Human Development; NICHD; National Institutes of Health; NIH.

This dual-component funding program will support collaborative research and project development projects that explore strategies to reduce medical error in both routine hospital settings and intensive care units. This funding cycle has an expiration due date of September 8, 2021.

Paradoxical Pulse

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February 1, 2011

A week after successful pacemaker placement, an elderly man developed chest pain and was admitted to the hospital without having an urgent echocardiogram. Although providers felt that he "looked fine," the patient became acutely hypotensive, developed ventricular tachycardia and pulseless electrical activity, and required emergent resuscitative measures for cardiac tamponade.

"Superficial" Report Leads to "Deep" Problem

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December 1, 2009

Physicians confuse the terminology on a preliminary radiology report and diagnose a woman with foot and ankle pain as having a low-risk case of superficial vein thrombosis, rather than the more dangerous deep vein thrombosis she actually had.

Delirium or Dementia?

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May 1, 2009

An elderly woman hospitalized for pneumonia becomes disoriented during hospitalization. Even though the patient was never confused at baseline, doctors attribute it to "senile dementia" and place her in restraints.

Undertriage of elderly trauma patients to state-designated trauma centers.

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Chang DC, Bass RR, Cornwell EE, et al. Arch Surg. 2008;143:776-782.

Elderly patients were systematically less likely to be transferred to a designated trauma center, despite appropriate clinical indications.

Where's the Feeding Tube?

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September 1, 2008

A boy was receiving enteral feedings while recovering from a traumatic brain injury. The nasojejunal tube migrated to the gastric area, and the patient developed pneumonia, likely due to aspiration.

Patient safety and quality in the pediatric intensive care unit.

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Ped Crit Care Med. 2007;8(2):s1-s43.

This supplement covers issues related to safety indicators, fatigue, electronic medical records, infection, and disclosure of medical errors in the care of critically ill children.

Did We Forget Something?

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September 1, 2003

A patient dies from infection and complications months after surgery; a retained sponge is found at autopsy.

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