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- Communication Improvement 9
- Culture of Safety 1
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- Error Reporting and Analysis 10
- Human Factors Engineering 1
- Legal and Policy Approaches 7
- Logistical Approaches 1
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- Quality Improvement Strategies 9
- Teamwork 4
- Technologic Approaches 3
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 4
- Identification Errors 1
- Medical Complications 1
- Medication Safety 6
- Nonsurgical Procedural Complications 5
- Psychological and Social Complications 2
- Surgical Complications 5
- Family Members and Caregivers 1
- Health Care Executives and Administrators 13
Health Care Providers
- Nurses 4
Non-Health Care Professionals
- Media 1
- Patients 15
Search results for "North America"
R3 Report. August 21, 2019;24:1-6.
Maternal safety in the United States is gaining momentum as a system-level patient safety concern. This report reviews the new Joint Commission Provision of Care, Treatment, and Services (PC) standards developed to improve the reliability of maternal care. Actions for improvement include patient risk assessment for conditions at admission and role-specific education for staff and providers who treat maternal patients regarding hemorrhage processes and procedures.
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.
ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019.
Newborns assigned temporary names are at increased risk for patient misidentification and wrong-patient errors. This newsletter article reports on the role of electronic health records in newborn misidentification and the unintended consequences associated with a Joint Commission set of recommendations to reduce risk.
Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm.
ISMP Medication Safety Alert! Acute Care Edition. October 4, 2018;23:1-4.
Increased urgency to prevent maternal mortality has uncovered various factors that diminish safety. This newsletter article reports on incidents involving the accidental misuse of epidural analgesia and intravenous antibiotics in labor and delivery care, describes contributing factors (e.g., health technology missteps, barcoding mistakes, and look-alike medications), and offers improvement strategies to mitigate harm.
Young A, Kelly J, Schnaars C, Ungar L. USA Today.
Quick Safety. March 27, 2018;(40):1-2.
Falls are a common patient safety concern for adults but are rarely discussed as a threat to newborn safety. This newsletter article provides a definition for a newborn fall or drop, highlights factors that increase risks of such incidents, and offers recommendations to augment safety such as rounding to monitor parent fatigue and reporting of events to inform improvements.
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.
New York, NY: ProPublica, Inc; 2017-2018.
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.
Veltman L. Patient Saf Qual Healthc. January/February 2015;12:34-36.
The Joint Commission and the American College of Obstetricians and Gynecologists have issued guidance regarding disruptive behaviors among clinicians. This magazine article provides an overview of incivility or disrespectful behavior in health care, how it can affect patient safety, and strategies to prevent such behaviors in the obstetrics and gynecology setting.
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.
O'Reilly KB. American Medical News. June 16, 2008;15:17.
This article reports on an initiative to prevent birth injuries through improved communication techniques and evidence-based care interventions.
Barbella M. Drug Topics. October 8, 2007;151:18.
This article reports how a failure to perform medication reconciliation during patient transfer led to a mother being separated from her newborn daughter for several months.
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.