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This piece discusses an expanded view of maternal and infant safety that includes the concept of whole-person care, which addresses the structural and social determinants of maternal health.

Alison Stuebe, MD, MSc, is a professor and Division Director for Maternal-Fetal Medicine in the Department of Obstetrics and Gynecology at the University of North Carolina (UNC) at Chapel Hill and the co-director of the Collaborative for Maternal and Infant Health. Kristin Tully, PhD, is a research assistant professor in the Department of Obstetrics and Gynecology at UNC Chapel Hill and a member of the Collaborative for Maternal and Infant Health.

A 61-year-old male was admitted for a right total knee replacement under regional anesthesia. The surgeon – unaware that the anesthesiologist had already performed a right femoral nerve block with 20 ml (100mg) of 0.5% racemic bupivacaine for postoperative analgesia – also infiltrated the arthroplasty wound with 200 mg of ropivacaine. The patient was sedated with an infusion of propofol throughout the procedure.

Mazzola SM, Grous C. AORN J. 2020;112:397-405.
This article describes strategies implemented by one hospital to help ensure patient and staff member safety during the COVID-19 pandemic, including use of personal protective equipment, decontamination efforts, mass temperature screenings, universal preprocedure testing, procedure prioritization, and modified workflows, as well as mental health support for front line clinicians and staff.
Giardina TD, Royse KE, Khanna A, et al. Jt Comm J Qual Patient Saf. 2020;46:282-290.
This study analyzed self-reported adverse events captured on a national online questionnaire to determine the association between patient-reported contributory factors and patient-reported physical, emotional or financial harm. Contributory factors identified in the analysis focused on issues with health care personnel communication, fatigue, or response (e.g., doctor was slow to arrive, nurse was slow to respond to call button). These patient-reported contributory factors increased the likelihood of reporting any type of harm.
Chicago, IL: American Hospital Association and Health Research & Educational Trust; September 2016.
The Partnership for Patients program has supported the Hospital Engagement Networks since 2011. This report reviews the results of the second round of funded effort, which involved more than 1500 hospitals in the United States that prevented 34,000 harms from September 2015 to September 2016. Areas of improvement included reductions in surgical site infections, adverse drug events, and postoperative complications. The authors also highlight core strategies of the program, such as evidence dissemination and coaching.
Pronovost P, Jha AK. N Engl J Med. 2014;371:691-693.
In this commentary, the authors raise concerns about the validity of large-scale reductions in patient harms and readmissions reported by the Partnership for Patients Hospital Engagement Networks initiative. They describe how lack of standardized measures and peer review to evaluate the interventions may affect the reliability of the results.

Rogers WA, ed. J Exp Psychol Appl. 2011;17(3):191-302.

Articles in this special issue explore the impact of cognition on health care activities such as patient identification, interruptions, and team communication.
Neily J, Mills PD, Lee P, et al. Qual Saf Health Care. 2010;19:360-4.
The Veterans Health Administration has pioneered implementation of several innovative safety interventions, including teamwork training (using the Medical Team Training model) for surgical and intensive care unit staff. This report on the early effects of the teamwork training initiative found positive perceptions of the impact on teamwork, communication, efficiency, and patient safety. This preliminary study also provides examples of changes in participant behavior and clinical outcomes associated with implementation of the teamwork program. Failure to report these outcomes is a common limitation of teamwork training studies, as discussed in a recent systematic review.

J Health Serv Research Policy. 2010;15(suppl 1):S1-S91. 

This journal supplement contains numerous articles, reviews, and commentaries pertaining to patient safety–related activities and research in the United Kingdom.
Reynard J, Reynolds J, Stevenson P. Oxford, UK: Oxford University Press; 2009. ISBN: 9780199239931.
This book provides an introduction to key patient safety topics and includes a set of 20 case studies to demonstrate opportunities for error prevention.
Following surgery for peripheral vascular disease, a patient otherwise ready for discharge complains of liquid shooting from his nose. The surgeons make the patient NPO and order a consultation from an otolaryngologist, who discovers the nasopharyngeal airway still lodged in the patient's nasal cavity.
Gardner E.
This article describes how one health system markedly improved its quality and safety by applying a safety technique used in the nuclear power industry.
Saufl NM. J Perianesth Nurs. 2009;24:114-8.
This commentary provides background on the development of the Joint Commission's 2009 National Patient Safety Goals and summarizes the goals set for the hospital environment.
Feinmann J. BMJ. 2009;338:b420.
This news article highlights a National Patient Safety Agency campaign to achieve safer care through five interventions.