Emerging Trends in Perinatal Quality and Risk With Recommendations for Patient Safety
In maternity and newborn care, the general health and young age of our patients often preclude an adverse outcome when conditions are such that the best care was not provided. This rare occurrence leads to a false assumption that the adverse event was a fluke rather than reflective of an underlying need to comprehensively evaluate routine operations and modify practice. Near misses are often not appreciated for their value in the ability to carefully review care and interdisciplinary communications that were involved in an open honest process without the anxiety and tension surrounding a patient injury. Hospitals, including those part of large health systems, often do not have robust reporting strategies to be able to identify trends in a timely manner and make a determination to change. Reporting criteria and systems vary widely among hospitals and are influenced by the safety culture on the unit. In a poor safety culture where there is fear of retribution and retaliation, no amount of effort, including lists of requirements and leadership requests, is going to generate reports that can lead to action for improvement. Critical data that could be used to improve care and minimize risk of preventable patient harm are frequently fragmented, unreported, and not fully understood. Transparency and timely sharing of these types of data within hospital systems can be vital in offering resources to support collective efforts to promote safe care.