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London UK: Crown Copyright; March 30, 2022. ISBN: 9781528632294.

Maternal and baby harm in healthcare is a sentinel event manifested by systemic failure. This report serves as the final conclusions of an investigation into 250 cases at a National Health System (NHS) trust. The authors share overarching system improvement suggestions and high-priority recommendations to initiate NHS maternity care improvement.

Ellis NT, Broaddus A. CNN. August 25, 2021. 

Maternal safety is an ongoing challenge worldwide. This news feature examines how the COVID pandemic has revealed disparities and implicit biases that impact the maternal care of black women. The stories shared highlight experiences of mothers with preventable pregnancy-related complications.

Kritz F. Shots. National Public Radio; May 24, 2021.

Health literacy efforts address challenges related to both language and effective communication tactics. This story discussed how lack of language and information clarity reduced patient education effectiveness during the pandemic and highlights several efforts to address them including information product translation services.

Centers for Disease Control and Prevention.

Ethnic and social inequities have a substantial impact on the safety and effectiveness of health care. This US Centers for Disease Control and Prevention (CDC) initiative provides access to science, CDC actions, and expert insights on the value of public health efforts to reduce the impact of systemic racism on health in the United States.

Zeynep Tufekci. The Atlantic. February 26, 2021

Failures in communication have impacts on patients, teams, organizations and society. This article discusses five weaknesses in pandemic messaging that were counterproductive including use of shaming instead of empathy to engage the public, lack of detail on suggested strategies and insufficient advice to support public adoption of harm reduction activities.

Washington, DC: United States Government Accountability Office; May 20, 2020. Publication GAO-20-576R.   

This US Government Accountability Office (GAO) report highlights the chronic shortfalls in nursing home infection control programs. The GAO analyzed survey data from the Centers for Medicare & Medicaid Services (CMS) and found 82% (13,299) of nursing homes surveyed were cited in one or more years between 2013-2017 and in each individual year, 40% of nursing homes had infection control and prevention deficiencies that continued through 2018 and 2019.  While the majority of the citations did not indicate harm to nursing home residents and were rarely associated with enforcement actions, the GAO intends to examine CMS oversight of infection and control in the near future.  In light of the COVID-19 pandemic, these findings are particularly concerning.