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Kowalczyk L. Boston Globe. July 29, 2017.
Maternal death is a sentinel event. This news article reports on two incidents at one hospital that prompted investigations and describes strategies to improve maternal safety, including standardizing procedures and enhancing communication.
A 'busy day' effect on perinatal complications of delivery on weekends: a retrospective cohort study.
Snowden JM, Kozhimannil KB, Muoto I, Caughey AB, McConnell KJ. BMJ Qual Saf. 2017;26:e1.
Study: clinicians copy and paste about half of text in EHR progress notes.
Landi H. Healthcare Informatics. June 1, 2017.
The second victim: a review.
Coughlan B, Powell D, Higgins MF. Eur J Obstet Gynecol Reprod Biol. 2017;213:11-16.
A boy's life is lost to sepsis. Thousands are saved in his wake.
Dwyer J. New York Times. April 13, 2017.
A systematic approach to the identification and classification of near-miss events on labor and delivery in a large, national health care system.
Clark SL, Meyers JA, Frye DR, McManus K, Perlin JB. Am J Obstet Gynecol. 2012;207:441-445.
Medicare study finds teaching hospitals have higher risk of complications; findings disputed.
Rau J. Washington Post. February 12, 2012:A03.
Near miss audit in obstetrics.
Penney G, Brace V. Curr Opin Obstet Gynecol. 2007;19:145-150.
How two rights can make a wrong.
Markel H. New York Times. February 25, 2007;4:5.
Maternity ward at Highland under fire from patients.
Vesely R. Inside Bay Area. December 28, 2006.
Do panels vary when assessing intrapartum adverse events? The reproducibility of assessments by hospital risk management groups.
Kernaghan D, Penney GC. Qual Saf Health Care. 2006;15:359-362.
Are the Agency for Healthcare Research and Quality obstetric trauma indicators valid measures of hospital safety?
Grobman WA, Feinglass J, Murthy S. Am J Obstet Gynecol. 2006;195:868-874.
Cause and effect analysis of closed claims in obstetrics and gynecology.
White AA, Pichert JW, Bledsoe SH, Irwin C, Entman SS. Obstet Gynecol. 2005;105:1031-1038.
Prescription opioid analgesics commonly unused after surgery: a systematic review.
Bicket MC, Long JJ, Pronovost PJ, Alexander CG, Wu CL. JAMA Surg. 2017 Aug 2; [Epub ahead of print].
Prescription opioid use, misuse, and use disorders in U.S. adults: 2015 National Survey on Drug Use and Health.
Han B, Compton WM, Blanco C, Crane E, Lee J, Jones CM. Ann Intern Med. 2017 Aug 1; [Epub ahead of print].
Association of changing hospital readmission rates with mortality rates after hospital discharge.
Dharmarajan K, Wang Y, Lin Z, et al. JAMA. 2017;318:270-278.
Improving adherence to long-term opioid therapy guidelines to reduce opioid misuse in primary care: a cluster-randomized trial.
Liebschutz JM, Xuan Z, Shanahan CW, et al. JAMA Intern Med. 2017 Jul 17; [Epub ahead of print].
In treating sepsis, questions about timing and mandates.
Abbasi J. JAMA. 2017;318:506-508.
Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use.
Bonnie RJ, Ford MA, Pillips JK, eds. Washington, DC: National Academies Press; 2017.
Double-booked: when surgeons operate on two patients at once.
Boodman SG. Kaiser Health News. July 12, 2017.
Non–health care facility medication errors resulting in serious medical outcomes.
Hodges NL, Spiller HA, Casavant MJ, Chounthirath T, Smith GA. Clin Toxicol (Phila). 2017 Jul 10; [Epub ahead of print].
Burnout Among Health Care Professionals. A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care.
Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Washington, DC: National Academy of Medicine; July 5, 2017.
Vital signs: changes in opioid prescribing in the United States, 2006–2015.
Guy GP Jr, Zhang K, Bohm MK, et al. MMWR Morb Mortal Wkly Rep. 2017;66:697-704.
A hospital is not just a factory, but a complex adaptive system—implications for perioperative care.
Mahajan A, Islam SD, Schwartz MJ, Cannesson M. Anesth Analg. 2017;125:333-341.
Do hospitals support second victims? Collective insights from patient safety leaders in Maryland.
Edrees HH, Morlock L, Wu AW. Jt Comm J Qual Patient Saf. 2017 Jun 29; [Epub ahead of print].
Perception of safety of surgical practice among operating room personnel from survey data is associated with all-cause 30-day postoperative death rate in South Carolina.
Molina G, Berry WR, Lipsitz SR, et al. Ann Surg. 2017 Jun 27; [Epub ahead of print].
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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