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Journal Article > Commentary
Slomski A. JAMA. 2019;321:1239-1241.
Maternal mortality is a sentinel event that affects mothers and families across a wide range of socioeconomic characteristics. This commentary explores how data collection gaps, medical errors, ineffective treatments, and care coordination weaknesses contribute to preventable maternal death. The author highlights efforts to improve safety in maternity care such as best practice bundles to ensure teams and clinicians are prepared for certain complications.
Journal Article > Study
A multidisciplinary model for reviewing severe maternal morbidity cases and teaching residents patient safety principles.
Ogunyemi D, Hage N, Kim SK, Friedman P. Jt Comm J Qual Patient Saf. 2019;45:423-430.
The rise in maternal morbidity and mortality is one of the most pressing patient safety issues in the United States. Formal debriefing after adverse events is an important method for analyzing and improving safety. In this study, an academic hospital adopted a systems-based morbidity and mortality conference model to review cases of serious maternal harm and implemented several safety measures (including teamwork training) to address issues that were identified through structured review.