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Perspectives on Safety > Interview
The Transformation of Patient Safety at the VA, September 2006
James P. Bagian, MD, is the Director of the Department of Veterans Affairs National Center for Patient Safety. Dr. Bagian began his career as a mechanical engineer, then became a physician, trained in surgery and anesthesia. A NASA Astronaut for 15 years, he flew on two space shuttle flights. In 2001, the American Medical Association awarded him the Nathan S. Davis Award for outstanding public service in the advancement of public health. We asked Dr. Bagian to speak with us about his experience transforming safety at in Veterans Affairs hospitals nationwide.
Web Resource > Multi-use Website
Dallas, TX: American College of Emergency Physicians.
This Web site provides access to emergency medical services evaluations in four categories: access, quality and patient safety, public health and prevention, and medical liability environment. The site also offers an interactive map of the nation, with detailed information and a "grade" for each state.
Graham J. Chicago Tribune. August 21, 2007;Metro section:1.
This article discusses a new Illinois state law that requires hospitals to screen all intensive care patients for methicillin-resistant Staphylococcus aureus (MRSA) infections and to isolate infected patients.
Journal Article > Study
Vital signs: pregnancy-related deaths, United States, 2011–2015, and strategies for prevention, 13 states, 2013–2017.
Petersen EE, Davis NL, Goodman D, et al. MMWR Morb Mortal Wkly Rep. 2019;68:423-429.
Maternal safety is a critical concern in health care, and prior studies have discussed racial and ethnic disparities in patient safety. The Centers for Disease Control and Prevention examined trends in pregnancy-related deaths between 2011 and 2015. This analysis found that black women had rates of maternal mortality 3.5 times that of white women; Native American/Alaska Native women had rates 2.5 times higher than white women. About 60% of deaths were deemed preventable, and leading causes included cardiovascular events such as venous thromboembolism, infection, and hemorrhage. The study team recommends implementing interventions at health system, provider, community, and patient levels to prevent maternal mortality. A recent Annual Perspective on maternal safety touched on the persistently higher death rates among black women and discussed national initiatives to improve outcomes in maternity care.