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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.

Health care safety during the pandemic and beyond--building a system that ensures resilience.

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Fleisher LA, Schreiber M, Cardo D, et al. N Engl J Med. 2022;386:609-611.

The COVID-19 pandemic disrupted many aspects of health care. This commentary discusses its impact on patient safety. The authors discuss how the pandemic response dismantled strategies put in place to prevent healthcare-associated infections and falls, and stressors placed on both patients and healthcare workers directed attention away from ongoing safety improvement efforts. They argue that more resilience needs to be built into the system to ensure safety efforts are sustainable in challenging times.

A crisis within a crisis.

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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.

Obstetric iatrogenesis in the United States: the spectrum of unintentional harm, disrespect, violence, and abuse.

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Liese KL, Davis-Floyd R, Stewart K, et al. Anthropol Med. 2021;28:188-204.

This article draws on interviews and observations to explore medical iatrogenesis in obstetric care. The authors discuss how various factors – such as universal management plans, labor and delivery interventions, and informed consent – contribute to iatrogenic harm and worse perinatal outcomes for racial/ethnic minority patients.

Telemedicine as a medical examination tool during the Covid-19 emergency: the experience of the onco-haematology center of Tor Vergata Hospital in Rome.

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Postorino M, Treglia M, Giammatteo J, et al. Int J Environ Res Public Health. 2020;17:8834.

Telehealth benefits, barriers, and challenges have become more apparent due to its increased use during the COVID-19 pandemic. This study evaluated 3,828 telehealth examinations (telephone, email) and found that the incidence of serious or minor adverse events was less than 0.50%.

Better nurse staffing is associated with survival for black patients and diminishes racial disparities in survival after in-hospital cardiac arrests.

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Brooks Carthon M, Brom H, McHugh MD, et al. Med Care. 2021;59:169-176.

Prior research has shown that lower nurse-to-patient ratios are associated with increased patient mortality. This cross-sectional analysis using multiple data sources from four states assessed the relationship between nurse staffing and survival disparities after in-hospital cardiac arrest. Results indicate that disparities in survival between black and white patients may be linked to medical-surgical nurse staffing levels, and that the benefit of being treated at a hospital with higher staffing ratios may be especially pronounced for black patients.

Development of rapid response capabilities in a large COVID-19 alternate care site using Failure Modes and Effect Analysis with in situ simulation.

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Levy N, Zucco L, Ehrlichman RJ, et al. Anesthesiology. 2020;133:985-996.

This article describes the experience of one hospital in eastern Massachusetts implementing rapid response capabilities in an innovative, hybrid acute care-intensive care unit. Health system leadership used failure modes and effect analysis, process mapping, and on-site walkthroughs to identify potential hazards and opportunities for risk mitigation, as well as in situ simulation drills to facilitate team training.

Containing COVID-19 in the emergency department: the role of improved case detection and segregation of suspect cases.

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Wee LE, Fua T‐P, Chua YY, et al. Acad Emerg Med. 2020;27:379-387.

This article describes the use of a broad suspect case criteria for detecting COVID-19 in the emergency department of one large, hospital in Singapore. Both the initial official case criteria and the broadened case definition, which included patients presenting with acute respiratory disease with no alternative etiology and a history of travel or residence in a country with ongoing local transmission were used with the broadened criteria having higher sensitivity. The broader criterion may increase the numbers of suspected positive cases but can help minimize nosocomial ED transmission.

Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic.

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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.

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