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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.

HEAR Her Concerns.

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National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health; Centers for Disease Control and Prevention.

Maternal harm during and after pregnancy is a sentinel event. This campaign encourages women, families, and health providers to identify and speak up with concerns about maternal care and act on them. The program seeks to inform the design of support systems and tool development that enhance maternal safety.

Racial and ethnic disparities in obstetric and gynecologic care and role of implicit biases.

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Bryant A. UpToDate. January 28, 2022.

Implicit bias is progressively being discussed as a detractor to safe health care by fostering racial and ethnic inequities. This review examines the history of health inequities at the patient, provider, health care system, and cultural levels in obstetric and gynecologic care. It shares actions documented in the evidence base for application in health care to reduce the impact of implicit bias, with an eye toward maternal care

Maternal mortality: near-miss events in middle-income countries, a systematic review.

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Heitkamp A, Meulenbroek A, van Roosmalen J, et al. Bull World Health Organ. 2021;99:693-707F.

Maternal safety is a patient safety priority. According to this systematic review including 69 studies, the maternal near miss incidence rate is estimated to be 15.9 cases per 1,000 live births in lower-middle income countries and 7.8 cases per 1,000 live births in upper-middle-income countries. The most common causes of near miss were obstetric hemorrhage and hypertensive disorders.

The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures, and lessons learned,

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Duzyj CM, Boyle C, Mahoney K, et al. Am J Perinatol. 2021;38:1281-1288.

Pregnancy and childbirth are recognized as high-risk activities for both the pregnant person and infant. This article describes the implementation of a postpartum hemorrhage patient safety bundle. Successes, challenges and recommendations for implementation are included.

Strengths and weaknesses in the diagnostic process of endometriosis from the patients' perspective: a focus group study.

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van der Zanden M, de Kok L, Nelen WLDM, et al. Diagnosis (Berl). 2021;8:333-339.

Endometriosis is a common clinical condition that is often subject to missed or delayed diagnosis. This qualitative study explored patients’ perspectives on the diagnostic process of endometriosis. Findings suggest that the diagnosis of endometriosis is hindered by delayed consultation, inadequate understanding and appraisal of symptoms by general practitioners, and inadequate communication between patients and providers.

Curated Libraries

Maternal Safety

FDA Safety Communication: update--robotically-assisted surgical devices in mastectomy.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.

This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.

Secondary traumatic stress in ob-gyn: a mixed methods analysis assessing physician impact and needs.

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Kruper A, Domeyer-Klenske A, Treat R, et al. J Surg Educ. 2021;78:1024-1034.

Physicians commonly experience adverse psychological outcomes after being involved in an adverse event. This mixed-methods study of health care providers in the Department of Obstetrics & Gynecology at one large academic hospital found that three-quarters of providers experienced symptoms of traumatic stress after involvement in an adverse event. Respondents reporting anxiety were more likely to be interested in peer-to-peer support programs, whereas those reporting symptoms of guilt preferred debriefing sessions.

The implementation of communication didactics for OB/GYN residents on the disclosure of adverse perioperative events.

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Chung EH, Truong T, Jooste KR, et al. J Surg Educ. 2021;78:942-949.

Medical residents are frequently involved in difficult patient conversations, including error disclosure. This paper describes the development and implementation of a novel communications/didactic skills training program for OB/GYN residents. Immediately, and 3-months after training, residents indicated an improvement in their communication skills.

Understanding the second victim experience among multidisciplinary providers in obstetrics and gynecology.

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Rivera-Chiauzzi E, Finney RE, Riggan KA, et al. J Patient Saf. 2022;18(2):e463-e469.

Using a validated tool, this study found that nearly 19% of clinical and nonclinical healthcare workers in obstetrics and gynecology settings reported a second victim experience within the last 12 months. Survey respondents who identified as a second victim reported significantly more psychological and physical distress, perceived inadequacy of institutional support, decreased professional self-efficacy, and increased turnover intentions. Prior research reported similar findings among nurses in obstetrics and gynecology.

Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough

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April 28, 2021

Two separate patients undergoing urogynecologic procedures were discharged from the hospital with vaginal packing unintentionally left in the vagina. Both cases are representative of the challenges of identifying and preventing retained orifice packing, the critical role of clear handoff communication, and the need for organizational cultures which encourage health care providers to communicate and collaborate with each other to optimize patient safety.

Endometriosis affects 1 out of 10 women like me. Yet it often takes a decade to get diagnosed.

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Peikoff L. NBC News. March 31, 2021.

Patients with endometriosis often experience care delays and misdiagnoses that contribute to harm. This news story discusses a patient’s experience with common contributors to delay that include Insufficient clinical knowledge of the disease and a lack of uniform treatment guidance.

Parent engagement in perinatal mortality reviews: an online survey of clinicians from six high-income countries.

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Boyle FM, Horey D, Siassakos D, et al. BJOG. 2020;128:696-703.

Patients, parents and caregivers play an important role in improving patient safety. Although parents have expressed interest in engaging in perinatal mortality review processes, this international survey of healthcare providers found that less than one-third of respondents (from various types of healthcare facilities) included parents in the review process at their institutions. The authors discuss the potential importance of parental involvement after perinatal mortality to improve care.

Second victim experiences of nurses in obstetrics and gynaecology: a Second Victim Experience and Support Tool Survey

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Finney RE, Torbenson VE, Riggan KA, et al. J Nurs Manag. 2021;29:642-652.

Healthcare professionals who experience emotional consequences after adverse events are referred to as ‘second victims’. Nearly half of nurses responding to this survey reported ‘second victim’ events during their career and experienced psychological distress, greater turnover intention, decreased professional self-efficacy, and lack of institutional support. Nurse respondents expressed desires for more peer support interventions for ‘second victim’ experiences.

Miscarriage treatment-related morbidities and adverse events in hospitals, ambulatory surgery centers, and office-based settings.

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Roberts SCM, Beam N, Liu G, et al. J Patient Saf. 2020;16:e317-e323.

The increase in maternal morbidity and mortality is a priority patient safety issue. This study compared miscarriage treatment-related morbidity and adverse events among hospitals, ambulatory surgery centers (ASCs), and office-based settings. Although there were slightly more events in hospitals than ASCs or office-based settings, study findings do not support limiting miscarriage treatment to a particular setting.

Obstetrician-gynecologist views of pregnancy-related medication safety.

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SteelFisher GK, Hero JO, Caporello HL, et al. J Womens Health (Larchmt). 2020;29:1113-1121.

This study explored views, practices, and needs related to patient counseling on medication safety in obstetrics and gynecology. Survey responses from over 500 OB/GYNs indicate opportunities to improve available resources and information sharing, such as developing new tools to communicate about teratogenic medications and pregnancy-safe over-the-counter medications and dietary supplements.

Long-term effects of teamwork training on communication and teamwork climate in ambulatory reproductive health care.

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Dodge LE, Nippita S, Hacker MR, et al. J Healthc Risk Manag. 2020;40:8-15.

The TeamSTEPPS program was developed to support effective communication and teamwork skills in healthcare settings. This evaluation assessed the long-term impact of implementing TeamSTEPPS in ambulatory reproductive health care centers. After two years, survey results indicate that TeamSTEPPS implementation was associated with improved perceptions of teamwork and patient satisfaction and that these tools and strategies were successfully integrated into health center operations.

Without an 'ounce of empathy': their stories show the dangers of being Black and pregnant.

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Ramaswamy SV. Rockland/Westchester Journal News. September 9, 2020.

Implicit and explicit biases affect many facets of the health care delivery system. This story shares African-American patient experiences with bias that reduced the safety of maternity care.

Doctors turned my sister away; less than two years later she died of cervical cancer.

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Harvey-Jenner C. Cosmopolitan. August 27, 2020.

Implicit biases are known to impact effective diagnosis. This story highlights how dismissed concerns resulted in a delay in cancer diagnosis that contributed to the death of a young woman.

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