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van der Zanden M, de Kok L, Nelen WLDM, et al. Diagnosis (Berl). 2021;8(3):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.

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.

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.
Kruper A, Domeyer-Klenske A, Treat R, et al. J Surg Educ. 2021;78(3):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.
Chung EH, Truong T, Jooste KR, et al. J Surg Educ. 2021;78(3):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.
Rivera-Chiauzzi E, Finney RE, Riggan KA, et al. J Patient Saf. 2021;Epub Apr 20.
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 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.

Boyle FM, Horey D, Siassakos D, et al. BJOG. 2020;128(4):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.
Finney RE, Torbenson VE, Riggan KA, et al. J Nurs Manag. 2021;29(4):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.
Roberts SCM, Beam N, Liu G, et al. J Patient Saf. 2020;16(4):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.
SteelFisher GK, Hero JO, Caporello HL, et al. J Womens Health (Larchmt). 2020;29(8):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.
Dodge LE, Nippita S, Hacker MR, et al. J Healthc Risk Manag. 2020;Epub Aug 8.
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.  
Noursi S, Saluja B, Richey L. J Racial Ethn Health Disparities. 2021;8(3):661-669.
This study used ecological systems theory to review the literature on the root causes of racial disparities in maternal morbidity and mortality at the individual, interpersonal, community, and societal levels. Factors influencing disparities include access to preconception and prenatal care, implicit bias among health care providers, the need for quality improvement among black-serving hospitals, and policies such as parental leave. The authors also identify interventions likely to reduce disparities, such as improving health professional education, alternate prenatal care providers, and reforming Medicaid policies.
Bontempo AC, Mikesell L. Diagnosis (Berl). 2020;7(2):97-106.
Endometriosis is a common clinical condition that is often subject to missed or delayed diagnosis. In this study of 758 patients with endometriosis, three-quarters reported being misdiagnosed with another physical and/or mental health problem, most commonly by their gynecologist or general practitioner.

Cumberlege J. London, England, Crown Copyright. July 8, 2020.

Implicit biases are known to affect the safety of health care. This analysis of the National Health Service (NHS) found weaknesses in NHS’ consideration of and response to women’s medication and medical device concerns. Among the recommendations submitted to improve patient centeredness and respect for patients are the establishment of central yet independent authority to serve as the conduit to address patient concerns and improve system safety accountability.
Endometriosis is a common clinical condition that is often subject to missed or delayed diagnosis. In this case, a mixture of shortcomings in clinicians’ understanding of the disease, diagnostic biases, and the failure to validate a young woman’s complaints resulted in a 12-year diagnostic delay and significant physical and psychologic morbidity.
Storesund A, Haugen AS, Flaatten H, et al. JAMA Surg. 2020;155(7):562-570.
This study assessed the impact of combined use of two surgical safety checklists on morbidity, mortality, and length of stay – the Surgical Patient Safety System (SURPASS) is used to address preoperative and postoperative care, and the World Health Organization surgical safety checklist (WHO SSC) is used for perioperative care.  In addition to existing use of the WHO SSC, the SURPASS checklist was implemented in three surgical departments in one tertiary hospital in Norway. Results demonstrated that combined use of these checklists was associated with reduced complications reoperations, and readmissions, but combined use did not impact mortality or length of stay.