Narrow Results Clear All
- Communication Improvement 6
- Culture of Safety 1
- Education and Training 6
- Error Reporting and Analysis 9
- Legal and Policy Approaches 5
- Logistical Approaches 2
- Quality Improvement Strategies 5
- Teamwork 3
- Technologic Approaches 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 3
- Medical Complications 1
- Medication Safety 4
- Nonsurgical Procedural Complications 4
- Surgical Complications 2
Search results for "North America"
CDC Vital Signs. May 7, 2019.
Maternal morbidity and mortality is a worldwide patient safety problem. This analysis describes the prevalence of pregnancy-related death and areas of concern during pregnancy, at delivery, and up to a year postpartum. It reports that 60% of these deaths are preventable and provides suggestions for families, clinicians, and systems to reduce risks.
Young A, Kelly J, Schnaars C, Ungar L. USA Today.
Montagne R. Weekend Edition Sunday. National Public Radio. March 11, 2018.
Maternal death is a sentinel event. This news audio segment reports on childbirth-related death in the United States and firsthand accounts of complications associated with childbirth, such as infection. The interview also discusses how misdiagnosis contributes to the severity of problems. This piece is part of an ongoing series on the safety of maternal care.
Kowalczyk L. Boston Globe. July 29, 2017.
Martin N, Montagne R. ProPublica and National Public Radio. May 12, 2017.
Maternal mortality is increasing in the United States. This news article reports on this critical safety problem in the context of the preventable death of a patient whose diagnosis of preeclampsia was missed by her providers, despite persistent concerns raised by family about the patient's symptoms.
Clark C. HealthLeaders Media. September 13, 2013.
This news piece highlights concern around the safety of elective premature deliveries and describes techniques organizations have used to prevent such procedures.
Landro L. Wall Street Journal. March 28, 2011.
This newspaper article discusses how combining best practices in teamwork, simulation, and communication can improve patient safety during obstetric emergencies.
Landro L. Wall Street Journal. February 18, 2009:D1.
This newspaper article discusses increasing concerns over potential burn injuries in the hospital setting and reports on efforts to raise awareness of the dangers and promote preventative measures.
Kowalczyk L. Boston Globe. March 29, 2007:4B.
This article reports on an award recognizing Beth Israel Deaconess Hospital for its approach to improving patient safety in response to the death of an infant in 2000.
Blaney B. Associated Press [USA Today]. March 12, 2007.
This article reports on the abduction of a newborn by an individual masquerading as a hospital employee. Infant abduction is one of the patient safety "never events" defined by the National Quality Forum.
Zimmerman R. Wall Street Journal. February 6, 2007:A1.
This article reports on a mother's campaign to educate parents about kernicterus and to make bilirubin tests standard for all newborns.
Vesely R. Inside Bay Area. December 28, 2006.
This article describes a variety of quality and safety problems in the labor and delivery ward at a large public hospital.
Wahlberg D, Treleven E. Wisconsin State Journal. November 3, 2006:A1.
This article reports on criminal charges brought against a nurse after she committed a medication error.
Landro L. Wall Street Journal. July 12, 2006:D1. [Reprinted on Post-gazette.com].
This article reports on efforts to reduce use of certain medications and instruments that can cause harm during labor and delivery.
Greene L. St. Petersburg Times. June 15, 2006:A1.
This article reports on the death of a pregnant 18-year-old after an overdose of magnesium sulfate.
Journal Article > Study
Cooper WO, Hernandez-Diaz S, Arbogast PG, et al. N Engl J Med. 2006;354:2443-2451.
This U.S. Food and Drug Administration (FDA)– and AHRQ–funded study documents the possibility of adverse effects on the fetus when mothers take angiotensin-converting enzyme (ACE) inhibitors during the first trimester of pregnancy.
Journal Article > Commentary
Sachs BP. JAMA. 2005;294:833-840.
Part of a series in JAMA entitled Clinical Crossroads, this case study discusses the unfortunate events surrounding a 38-year-old woman's presentation to a labor and delivery unit. The case details a seemingly routine full-term pregnancy that rapidly evolved into a course of complications, ultimately leading to a fetal death, a hysterectomy, and a prolonged hospital course. The discussion shares the experience through the eyes of the patient, her husband, and the primary obstetrician. Further exploration of the case identified several specific factors and broader systems issues that contributed to the events. The author shares how this particular institution responded with overarching changes, including a greater emphasis on teamwork, communication, and appropriate staffing of labor and delivery units to promote safety.
Audiovisual > Audiovisual Presentation
Producer: Partnership for Patient Safety & Risk Management Foundation. Chicago, IL: Partnership for Patient Safety; 2000.
This video, produced by the Partnership for Patient Safety and the Harvard Risk Management Foundation, presents a series of missteps involving a healthy obstetric patient and her unborn infant. Based on actual facts drawn from the experience of the Risk Management Foundation of the Harvard Medical Institutions, this 18-minute film illustrates the value of having a systems awareness in medicine. Deeper explorations of teamwork, hand-offs, communication skills, and managing the authority gradient provide rich examples for viewers. Parts 2 and 3 complete the video series.