Saving Mothers' Lives: Reviewing Maternal Deaths to Make Motherhood Safer—2003–2005.

Book/Report

Saving Mothers' Lives: Reviewing Maternal Deaths to Make Motherhood Safer—2003–2005.

January 2, 2008

Lewis G, ed. London, England: Confidential Enquiry into Maternal and Child Health; 2007. ISBN: 9780953353682.

View more articles from the same authors.

This United Kingdom report notes that ineffective communication and teamwork contributed to incidents of low-quality care. It also includes ten recommendations for improving general maternal care as well as a chapter on outcomes specific to anesthesiology-related failures.

Free full text (PDF)

Related Resources From the Same Author(s)

Deaths in Acute Hospitals: Caring to the End?

November 25, 2009

Safer Care for the Acutely Ill Patient: Learning from Serious Incidents.

October 24, 2007

Culture Change in the NHS: Applying the Lessons of the Francis Inquiries.

March 11, 2015

Hard Truths: the Journey to Putting Patients First.

November 27, 2013

Learning Not Blaming.

September 9, 2015

'Reading the Signals' : Maternity and Neonatal Services in East Kent – the Report of the Independent Investigation.

November 16, 2022

Gosport War Memorial Hospital. The Report of the Gosport Independent Panel.

November 7, 2018

State of Healthcare 2008.

January 7, 2009

Patient Safety Culture: Theory, Methods and Application.

January 21, 2015

Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer.

June 4, 2014

Clinical Risk Management. Enhancing Patient Safety. 2nd ed.

March 27, 2005

Raising and Responding to Concerns.

February 25, 2015

Patient Safety Incident Response Framework.

August 31, 2022

Saying Sorry.

March 26, 2014

Government Response to the Investigation into the Death of Elizabeth Dixon.

June 14, 2023

Managing the Costs of Clinical Negligence in Trusts.

October 4, 2017

Improving Diagnosis: Teenage Cancer Trust Report on Improving the Diagnostic Experience of Young People With Cancer.

December 4, 2013

The Report of the Short Life Working Group on Reducing Medication-related Harm.

March 28, 2018

Getting Results: Reliably Communicating and Acting on Critical Test Results.

July 12, 2006

Safety First: One Year On.

January 9, 2008

High Quality Care for All: NHS Next Stage Review Final Report.

July 16, 2008

Oxford Professional Practice: Handbook of Patient Safety.

July 27, 2022

Gross Negligence Manslaughter in Healthcare: The Report of a Rapid Policy Review.

July 25, 2018

Solutions from Professional Regulation and Beyond.

October 5, 2022

A Promise to Learn—a Commitment to Act: Improving the Safety of Patients in England.

August 21, 2013

Digital Clinical Safety Strategy

October 20, 2021

Good for You, Good for Us, Good for Everybody.

October 6, 2021

Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984--1995.

April 25, 2007

The Report of the Morecambe Bay Investigation.

April 29, 2015

The Life and Death of Elizabeth Dixon: A Catalyst for Change.

December 9, 2020

Coding for Success: Simple Technology for Safer Patient Care.

March 14, 2007

Using Safety Cases in Industry and Healthcare.

February 13, 2013

Magnet in Support of Patient Safety.

November 26, 2014

Continuous Improvement of Patient Safety: The Case for Change in the NHS.

November 25, 2015

Ignoring the Alarms: How NHS Eating Disorder Services Are Failing Patients.

March 28, 2018

Safety-I and Safety-II: The Past and Future of Safety Management.

August 20, 2014

Managing the Risks of Organizational Accidents.

March 27, 2005

Freedom to Speak Up: A Review of Whistleblowing in the NHS.

May 27, 2015

Complaints and Raising Concerns.

February 4, 2015

The Safety of Maternity Services in England.

August 25, 2021

Third Annual Report on Adverse Health Events in Wyoming Healthcare Facilities.

February 11, 2009

Learning From Mistakes.

August 31, 2016

Quality and Safety in Nursing: a Competency Approach to Improving Outcomes, Second Edition.

May 17, 2017

The Habits of an Improver. Thinking About Learning for Improvement in Health Care.

December 16, 2015

Learning from Investigations.

February 20, 2008

Beyond the Data: Understanding the Impact of COVID-19 on BAME Groups.

July 1, 2020

National Confidential Enquiry into Patient Outcome and Death.

March 6, 2005

2011 Annual Benchmarking Report: Malpractice Risks in Emergency Medicine.

September 26, 2012

Guidance on Safe Medical Staffing: Report of a Working Party.

August 1, 2018

Report of the Independent Inquiry into the Issues Raised by Paterson.

February 19, 2020

Medication Errors. 2nd ed.

November 1, 2006

BMJ Open Quality.

September 17, 2014

The Measurement and Monitoring of Safety.

May 8, 2013

Safety in Doses.

September 16, 2009

Review of Patient Safety for Children and Young People.

July 1, 2009

Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry.

February 20, 2013

Zero: Eliminating Unnecessary Deaths in a Post-pandemic NHS.

June 22, 2022

Independent Neurology Inquiry.

July 20, 2022

Organizing Patient Safety: Failsafe Fantasies and Pragmatic Practices.

May 8, 2019

Investigating Clinical Incidents in the NHS.

May 6, 2015

Safely Home: What Happens When People Leave Hospital Care Settings?

August 26, 2015

Improving Patient Safety Culture – A Practical Guide.

August 2, 2023

Patient Safety and Managing Risk in Nursing.

January 15, 2014

Learning how to learn: compliance with patient safety alerts in the NHS.

August 3, 2005

Avoiding Unconscious Bias: a Guide for Surgeons.

August 24, 2016

Surgical Innovation, New Techniques and Technologies: A Guide to Good Practice.

May 29, 2019

Learning From Invited Reviews.

April 10, 2019

PHSO Review: Quality of NHS Complaints Investigations.

June 22, 2016

Safer Clinical Systems: Evaluation Findings.

February 18, 2015

Principles of Risk Management and Patient Safety.

March 9, 2011

Impact of Medical Errors and Malpractice on Health Economics, Quality, and Patient Safety.

April 26, 2017

Improving Healthcare Team Communication: Building on Lessons from Aviation and Aerospace.

June 25, 2008

Improving Safety in Maternity Services: a Toolkit for Teams.

April 25, 2012

How Doctors Think.

March 28, 2007

Standardise, Educate, Harmonise: Commissioning the Conditions for Safer Surgery.

April 23, 2014

Safety and Ethics in Healthcare: A Guide to Getting it Right.

October 10, 2007

Error Reduction in Health Care: A Systems Approach to Improving Patient Safety, Second edition.

June 1, 2011

Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. 2nd ed.

February 13, 2017

Misadventures in Health Care: Inside Stories.

August 24, 2005

Medical Problem Solving: An Analysis of Clinical Reasoning.

March 27, 2005

Bias in the ER. Doctors suffer from the same cognitive distortions as the rest of us.

February 22, 2017

Managing Patients' Medicines after Discharge from Hospital.

November 11, 2009

First Do No Harm. The Report of the Independent Medicines and Medical Devices Safety Review.

July 22, 2020

The Role of Hospitalists in Patient Safety.

December 2, 2009

The Value of Close Calls in Improving Patient Safety.

February 2, 2011

Patient Safety.

July 15, 2009

Improving Usability, Safety and Patient Outcomes With Health Information Technology.

February 27, 2019

Infection Prevention.

May 27, 2015

First, Do Less Harm: Confronting the Inconvenient Problems of Patient Safety.

June 6, 2012

Surgical Patient Safety: A Case-Based Approach.

October 18, 2017

SHOT Annual Report.

July 19, 2023

Acting on Concerns: Your Professional Responsibility.

March 6, 2013

Patient Safety in the Context of Perinatal, Neonatal, and Pediatric Care.

June 22, 2011

Implementing Patient Safety: Addressing Culture, Conditions and Values to Help People Work Safely.

October 23, 2019

Building a Culture of Candour: a Review of the Threshold for the Duty of Candour and of the Incentives for Care Organisations to Be Candid.

April 2, 2014

The Anatomy of Medical Error: Preventing Harm with People-Based Patient Safety.

October 25, 2006

Reporting and Learning Systems for Medication Errors: The Role of Pharmacovigilance Centres.

November 19, 2014

HSMR: A New Approach for Measuring Hospital Mortality Trends in Canada.

December 12, 2007

Quality and Safety Education for Nurses.

June 13, 2007

Patient Safety 2030.

April 6, 2016

Related Resources

Annual Perspective

Equity in Patient Safety

March 27, 2024

Annual Perspective

Communication During Transitions of Care

March 27, 2024

Patient Safety Innovations

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

January 31, 2024

Investigators find hospital error caused mother’s death in Brooklyn.

January 24, 2024

MHA and MHA Keystone Center Annual Reports.

October 20, 2023

Interview

In Conversation with... Kathleen Sanford and Sue Schuelke about Virtual Nursing

August 30, 2023

Perspectives on Safety

Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges

August 30, 2023

A call for safety: anticipating and mitigating risk across an obstetrics and gynecology service line.

June 21, 2023

'Reading the Signals' : Maternity and Neonatal Services in East Kent – the Report of the Independent Investigation.

November 16, 2022

Maternity Pre-arrival Instructions by 999 Call Handlers.

March 16, 2022

Each Baby Counts.

April 1, 2021

Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective cohort study.

February 17, 2021

Developing perioperative Covid-19 testing protocols to restore surgical services.

July 22, 2020

Implementation of a comprehensive unit-based safety program to reduce surgical site infections in cesarean delivery.

April 22, 2020

Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals NHS Foundation Trust.

April 15, 2020

The Diagnosis of Ectopic Pregnancy.

April 8, 2020

Investigation into Detection of Retained Vaginal Swabs and Tampons Following Childbirth.

January 22, 2020

Emerging Concepts in Patient Safety.

September 18, 2019

PC standards for maternal safety.

September 11, 2019

Individual and team-based medical error disclosure: dialectical tensions among health care providers.

August 28, 2019

Quality and Safety in Anesthesia and Perioperative Care.

July 17, 2019

Medication Safety in Key Action Areas.

July 10, 2019

The rise of human factors: optimising performance of individuals and teams to improve patients' outcomes.

July 10, 2019

Cultural Issues Related to Allegations of Bullying and Harassment in NHS Highland: Independent Review Report.

June 26, 2019

Observer-based tools for non-technical skills assessment in simulated and real clinical environments in healthcare: a systematic review.

June 12, 2019

Safer Hospital Care: Strategies for Continuous Innovation, Second Edition.

May 16, 2019

Impact of teamwork improvement training on communication and teamwork climate in ambulatory reproductive health care.

May 1, 2019

Improving patient safety in developing countries—moving towards an integrated approach.

February 6, 2019

Partnership for Patients (PfP) Hospital Engagement Network (HEN) 2.0 Final Report.

October 19, 2016

The 'go-between' study: a simulation study comparing the 'Traffic Lights' and 'SBAR' tools as a means of communication between anaesthetic staff.

September 21, 2016

See More About The Topic

Health Care Executives and Administrators

Anesthesiology

Obstetrics

Quality Improvement Strategies

Communication Improvement