The PSNet Collection

Maternal Safety

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.

Wrong-site surgery in Pennsylvania during 2015–2019: a study of variables associated with 368 events from 178 facilities.

Yonash RA, Taylor M. Patient Safety. 2020;2(4):24-39.

Wrong-site surgeries can lead to serious patient harm and are considered never events by the National Quality Forum. Based on events reported to the Pennsylvania Patient Safety Reporting System between 2015 and 2019, the authors identified an average of 1.42 wrong-site surgery events per week and found that three-quarters of events resulted in temporary or permanent patient harm. The authors present several evidence-based strategies to reduce the likelihood of wrong-site surgery, including preoperative and intraoperative verification, site marking, and timeouts.

A night in the hospital, from both ends of the stethoscope.

Ofri D. New York Times. January 5, 2021.

Physicians have unique perspectives when exposed to health care delivery problems as patients themselves or as caregivers. This news story shares the author’s frustrations with the system of care observed during an overnight visit at the bedside of her daughter awaiting an emergency appendectomy. Her experience underscored the value of patients and families engaging in the safety of actions clinicians take when providing care.

Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association.

Soncrant C, Mills PD, Neily J, et al. J of Patient Saf. 2020;16.

In this retrospective review of root cause analysis (RCA) reports of select gastrointestinal procedures, researchers identified 27 adverse events 30-month period. Nearly half (48%) of events caused major or catastrophic harm. The most frequently reported adverse events were attributable to human factors (22%), medication errors (22%) or retained items; retained items were associated with the most harm.

Using video to assess and improve patient safety during simulated and actual neonatal resuscitation.

Leone TA. Semin Perinatol. 2019;43:151179.

Resuscitations are highly complex interventions, particularly in neonatal settings. Ineffective teamwork, poor communication, and knowledge deficits in the neonatal team can result in adverse patient outcomes. Video is one approach to mitigating these issues by providing education, practice simulations, and skill assessment in order to improve patient care.

Maternal Safety

September 7, 2019

Pregnancy, childbirth, and the postpartum year present a complex set of patient safety challenges. Numerous maternal safety initiatives aim to prevent errors and harm, while enhancing readiness to address maternal complications.

Burnout and Resilience and Quality and Safety Programs in Obstetrics and Gynecology.

Main EK, Fowler JM, Gabbe SG, eds. Clin Obstet Gynecol. 2019;62:vii-xii,403-626.

Obstetrics is a high-risk practice that concurrently manages the safety of mothers and newborns. Articles in this special issue discuss how to address burnout and support resilience in obstetrics and gynecology care. Tactics covered include bundles, checklists, and collaboratives.

Delivering high reliability in maternity care: in situ simulation as a source of organisational resilience.

Macrae C, Draycott T. Safety Sci. 2016;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.

Failure to Rescue the Mother

July 2, 2019

First admitted to the hospital at 25 weeks of pregnancy for vaginal bleeding, a woman (G5 P2 A2) received 4 units of packed red blood cells and 2 doses of iron injections. She was discharged after 3 days with an improved hemoglobin level. At 35 weeks, she was admitted for an elective cesarean delivery. Intraoperatively, an upper uterine segment incision was made and the newborn was delivered in good condition. Immediately after, a subtotal hysterectomy was performed. The anesthesiologist noted that the patient was hypotensive; blood was transfused.

A safety evaluation of the impact of maternity-orientated human factors training on safety culture in a tertiary maternity unit.

Ansari SP, Rayfield ME, Wallis VA, et al. J Patient Saf. 2020;16(4):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.

Obstetric practice guidelines: labor's love lost?

Cohen WR, Friedman EA. J Matern Fetal Neonatal Med. 2019;32(9):1567-1570.

Guidelines play an important role in enhancing safety and reliability, but they must be rigorously evidence-based, followed, and applied. This commentary suggests that overconfidence in the guideline development process can result in reliance on recommendations that misinform practice and contribute to patient harm. As an example, the authors discuss the wide adoption of a guideline to address the cesarean delivery rate that omitted important clinical prognosticators.

Patient Safety in Obstetrics and Gynecology.

Gluck PA, ed. Obstet Gynecol Clin North Am. 2019;46:H1-H8, 199-398.

Obstetrics is a high-risk practice that concurrently manages the safety of mothers and newborns. Articles in this special issue explore various facets of health care quality and safety improvement in the care of women and expectant mothers. Topics covered include the patient experience, safety culture, disparities, program implementation, and clinical trends.

In-situ interprofessional perinatal drills: the impact of a structured debrief on maximizing training while sensing patient safety threats.

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.

Understanding the heterogeneity of labor and delivery units: using design thinking methodology to assess environmental factors that contribute to safety in childbirth.

Sherman JP, Hedli LC, Kristensen-Cabrera AI, et al. Am J Perinatol. 2020;37(6):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.

How to reduce maternal mortality rates in the United States.

Livingston E, Howell EA. JAMA Clinical Reviews. 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.

Recommendations from a national panel on quality improvement in obstetrics.

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.

A multidisciplinary model for reviewing severe maternal morbidity cases and teaching residents patient safety principles.

Ogunyemi D, Hage N, Kim SK, et al. Jt Comm J Qual Patient Saf. 2019;45(6):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.

Why do hundreds of US women die annually in childbirth?

Slomski A. JAMA. 2019;321(13):1239-1241.

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.

A qualitative evaluation of healthcare professionals' perceptions of adverse events focusing on communication and teamwork in maternity care.

Rönnerhag M, Severinsson E, Haruna M, et al. J Adv Nurs. 2019;75:585-593.

Inadequate communication in obstetrics can compromise safety. In this qualitative study, researchers conducted focus groups of multidisciplinary teams including obstetricians, midwives, and nurses working in a single maternity ward to examine their perceptions of adverse events during childbirth. Analysis of data collected suggests that support for high-quality interprofessional teamwork is important for safe maternity care.

New mother number 14.

Sangarlangkarn A.

Rigid adherence to protocols may detract from safety when unexpected critical events occur that require deviation from the standard process. This commentary explores insights from a physician, both as a clinician and as a new mother, when health care staff failed to effectively consider patient concerns and knowledge in understanding and treating the cause of postlabor pain. The patient identified the cause and requested appropriate treatment, but nurses consulted protocols for pain after labor and only offered pain medications, which might have exacerbated the problem. The author calls for clinician autonomy to recognize when standardization is not appropriate and how to address individual patient needs.

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