Newsletter
AMC PSO Patient Safety Alert Issue 9
Dec 31, 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
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More AMC PSO Content
Publications such as whitepapers and guidelines derived from the AMC PSO convenings.
Programmable Medical Equipment Risks and Interventions
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The AMC PSO has identified a series of practices employed to address the factors that can contribute to risk associated with programmable medical devices.
Wrong Site Surgery Report
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The AMC PSO has identified the a series of practices employed to address the factors that can contribute to a wrong-site surgery.
The Risks of Programmable Medical Equipment
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The AMC PSO has identified a broad array of programmable medical devices and made several recommendations to decrease risk due to user fallibility, equipment complexity, and highly variable processes.
PCA Pump Alarm Safety Concerns
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The AMC PSO has identified a series of practices employed to address the factors that can contribute to risk associated with ambulatory pumps.
The Safety of Inpatient Health Care
News
Funded by CRICO, The Safety of Inpatient Health Care study published in the New England Journal of Medicine on January 12, 2023 is an important follow up to the landmark Harvard Medical Practice Study (HMPS), published in 1991.