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.
Levtzion-Korach O, Alcalai H, Orav EJ, et al. J Patient Saf. 2009;52:9-15.
The limitations of standard incident reporting systems have been well documented. Although ubiquitous and relatively easy to use, such systems detect only a fraction of adverse events, are underused by physicians, and yield data that often are not analyzed or disseminated promptly. This analysis of data from a commercial, web-based system at an academic hospital confirms some prior concerns, but the authors were able to demonstrate that rapid review of reports resulted in specific system changes to improve workflow and safety. A prior article presented a framework for using incident reporting data to improve patient safety.
Following spinal surgeries, two different patients developed tachycardia, hypotension, and hypoxia due to sepsis. Given the similarity in clinical course, the hospital investigated and found that both patients had received platelets contaminated with Staphylococcus aureus.
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