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.

This matched case-control study examined costs and payments to hospitals related to hospital-acquired central line infections and catheter-associated urinary tract infections. Investigators found that hospitals could either experience financial penalty or gain depending on the particular payment structure for the patient. They suggest aligning payment structures more closely with safety goals.

Wrong-site surgery represents a never event. In the United States, The Joint Commission requires marking of the surgical site prior to surgery as part of the Universal Protocol. Researchers conducted a survey study of 120 surgeons in the United Kingdom and found significant variation in adherence to the national mandate for preoperative surgical site-marking.

Reporting on the investigation into an incident where five pediatric patients died after acquiring a health care–associated infection, this newspaper article describes how delays in diagnosis and treatment along with inadequate communication contributed to patient harm.

This commentary details a National Health Service trust's experience implementing a patient safety measurement tool that incentivized improvement in four areas: falls, pressure ulcers, venous thromboembolisms, and catheter-associated urinary tract infections.