Newsletter
Patient Safety in Labor and Delivery: Managing Complex Conditions in a Complex Environment
Dec 28, 2012
Patient Safety Alert 9: Patient Safety in Labor and Delivery: Managing Complex Conditions in a Complex Environment (PDF)
The AMC PSO in conjunction with CRICO’s Patient Safety Department has continued to analyze OB-related malpractice claims along with real-time root cause analysis information to identify trends, respond to present system vulnerabilities, and educate members on new emerging risks.
Alert
Issues related to management of second stage labor predominate and are addressed below:
- Human Factor Issues: Failure to accurately assess and document maternal-fetal status including: cervical dilation, effacement and membrane status, and fetal heart rate pattern
AMC PSO
Our Patient Safety Organization convenes clinical leaders to identify and mitigate emerging risks.
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More AMC PSO Content
Publications such as whitepapers and guidelines derived from the AMC PSO convenings.
Guidance to Reduce the Risk of Retained Surgical Items
Newsletter
Patient Safety Alert Issue 33: Experts found three main categories of risk related to RSI: distractions, hand offs, and relationships/trust. Discover their strategies and best practices found to reduce risk in each of these areas.
Patient Falls
Newsletter
Patient Safety Alert Issue 23: The AMC PSO convened a panel of nursing leaders to review recent trends, evaluate the current literature, and discuss novel interventions aimed at mitigating the risk regarding patient falls.
Periprocedural Management of Anticoagulation Therapy
Newsletter
Patient Safety Alert Issue 24: The AMC PSO recently convened to discuss this high-risk area and important patient safety issue, the contributing factors often associated with this medication event type, and the strategies to proactively mitigate this risk.
Non-Operating Room Anesthesia Self-Assessment Tool
Newsletter
Patient Safety Alert Issue 35: This document identifies areas of vulnerability and offers a self-assessment table to help organizations evaluate existing NORA settings and identify strengths and opportunities for providing safe care.
Medication Errors and Malpractice: What a Decade of Cases Reveals About Risk Across the Care Continuum
News
Published in MPLA’s Inside Medical Liability, the article uses a decade of Candello med mal data to highlight medication error risks and the need for coordinated safeguards across every stage of care.
Establishing a Regional Registry for Neonatal Encephalopathy: Impact on Identification of Gaps in Practice
News
CRICO Grants
Neonatal encephalopathy continues to be a significant risk for death and disability. To address this risk, regional guidelines were developed with the support of CRICO. A neonatal encephalopathy registry was also established. The aim of this study was to identify areas of variation in practice that could benefit from quality improvement projects.
Postpartum Malpractice Claims: Can We Understand Preventable Harms and Socioeconomic Factors?
News
Candello Member
In a multifactorial study, The Doctors Company (a Candello member organization) investigated postpartum claims to develop clinical recommendations to decrease the risks of postpartum morbidity and mortality.
Utilization of Electronic Health Record Sex and Gender Demographic Fields: A Metadata and Mixed Methods Analysis
News
CRICO Grants
This CRICO co-funded retroactive study published in the Journal of the American Medical Informatics Association analyzed the records of patients 18 years of age or older in the Mass General Brigham health system with a first Legal Sex entry (registration requirement) between 2018 and 2022. The study was important because “Sex and gender demographic data are widely viewed as essential to providing culturally responsive gender affirming care and facilitating research and public health interventions.”