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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality.html
September 01, 2021 - Safety and Quality
Issue Briefs
The Contribution of Diagnostic Errors to Maternal Morbidity … Safety and Quality in Healthcare
The Contribution of Diagnostic Errors to Maternal Morbidity … Contents
Introduction The Contribution of Diagnostic Error to Maternal Mortality and Severe Maternal Morbidity … The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After … EF
Related Publications
The Contribution of Diagnostic Errors to Maternal Morbidity
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-2.html
September 01, 2021 - Briefs
The Contribution of Diagnostic Error to Maternal Mortality and Severe Maternal Morbidity … Safety and Quality in Healthcare
The Contribution of Diagnostic Errors to Maternal Morbidity … State of the Science
The Contribution of Diagnostic Error to Maternal Mortality and Severe Maternal Morbidity … Previous Page Next Page
Table of Contents
The Contribution of Diagnostic Errors to Maternal Morbidity … Internet Citation: The Contribution of Diagnostic Error to Maternal Mortality and Severe Maternal Morbidity
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-1.html
September 01, 2021 - Safety and Quality in Healthcare
The Contribution of Diagnostic Errors to Maternal Morbidity … Previous Page Next Page
Table of Contents
The Contribution of Diagnostic Errors to Maternal Morbidity … Maternal mortality is thought of as the “tip of the iceberg,” as severe maternal morbidity has similar … Severe maternal morbidity (SMM) is defined as an unintended outcome of birth that results in significant … . 8,10
Similar to maternal mortality, multidisciplinary review shows that maternal morbidity is associated
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-4.html
September 01, 2021 - Safety and Quality in Healthcare
The Contribution of Diagnostic Errors to Maternal Morbidity … Previous Page Next Page
Table of Contents
The Contribution of Diagnostic Errors to Maternal Morbidity … and the American College of Obstetricians and Gynecologists have advocated for solutions to maternal morbidity … This approach and agenda can be applied to other causes of maternal morbidity and mortality, such as … Apply lessons learned from trends and improvements in morbidity and mortality due to various comorbidities
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-6.html
September 01, 2021 - A descriptive model of preventability in maternal morbidity and mortality. … Severe maternal morbidity: screening and review. … Severe Maternal Morbidity in the United States. … The continuum of maternal morbidity and mortality: factors associated with severity. … Importance of research in reducing maternal morbidity and mortality rates.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-issuebrief-maternal-morbidity.pdf
September 01, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After … A descriptive model of preventability in maternal morbidity and
mortality. … Severe maternal morbidity: screening and review. … The
continuum of maternal morbidity and mortality: factors associated with severity. … Importance of research in reducing maternal morbidity and mortality rates.
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-5.html
September 01, 2021 - Safety and Quality in Healthcare
The Contribution of Diagnostic Errors to Maternal Morbidity … Previous Page Next Page
Table of Contents
The Contribution of Diagnostic Errors to Maternal Morbidity … Science
Introduction
The Contribution of Diagnostic Error to Maternal Mortality and Severe Maternal Morbidity … Improvement Tools
Research Agenda
Conclusions and Next Steps
References
Maternal morbidity
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Deis_82.pdf
June 03, 2008 - Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement
Transforming … the Morbidity and Mortality Conference
into an Instrument for Systemwide Improvement
Jamie N. … The morbidity and mortality conference:
The delicate nature of learning from error. … Using prospective outcomes data to
improve morbidity and mortality conferences. … Discussion of medical errors in morbidity
and mortality conferences.
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-3.html
September 01, 2021 - Safety and Quality in Healthcare
The Contribution of Diagnostic Errors to Maternal Morbidity … Previous Page Next Page
Table of Contents
The Contribution of Diagnostic Errors to Maternal Morbidity … Science
Introduction
The Contribution of Diagnostic Error to Maternal Mortality and Severe Maternal Morbidity … with adoption of this safety bundle 23 led to a 21 percent reduction in severe maternal hemorrhage morbidity … Addressing Implicit Bias, Structural Barriers, and Social Determinants of Health
Severe maternal morbidity
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care-2/index.html
July 01, 2023 - hypertension in pregnancy, two leading known causes of preventable maternal mortality and severe maternal morbidity … Background
To address the leading known causes of preventable maternal mortality and severe maternal morbidity … for obstetrical and perinatal conditions that contribute to maternal mortality and severe maternal morbidity … components, given the major contribution of these conditions to maternal mortality and severe maternal morbidity … Clinicians
As the heart of patient care and management of maternal mortality and severe maternal morbidity
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/mcc-summit/mcc-summit-arlene.pdf
November 17, 2020 - new
investigator-initiated grants focused on
multiple chronic conditions (MCC).
4
MCC, Multi-morbidity … • Multi-morbidity, a term often used synonymously with
MCC, includes those with more than one chronic … physical
condition, more than one mental health diagnosis, or both
• Others use the term multi-morbidity … AHRQ FY 21 Presidential Budget
MCC, Multi-morbidity or Burden of Illness?
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ce.effectivehealthcare.ahrq.gov/research/findings/nhqrdr/2014chartbooks/womenhealth/wm-eff.html
September 01, 2015 - National Healthcare Quality & Disparities Reports
Effective Treatment of Leading Causes of Morbidity … Chartbook on Women's Health Care
Effective Treatment of Leading Causes of Morbidity … Care
Affordability
Communication and Care Coordination
Effective Treatment of Leading Causes of Morbidity … originally created October 2015
Internet Citation: Effective Treatment of Leading Causes of Morbidity
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ce.effectivehealthcare.ahrq.gov/news/newsletters/e-newsletter/882.html
September 01, 2023 - September 26, 2023
AHRQ Stats: Trends in Severe Maternal Morbidity Between 2012 and 2019
Severe maternal … morbidity rates in the United States increased 15 percent from 69.5 events per every 10,000 deliveries … Among 20 indicators of severe maternal morbidity, acute kidney failure had the greatest increase, from … (Source: JAMA Network Open , Trends in Severe Maternal Morbidity in the US Across the Transition from … publications in PSNet’s current issue or access recent cases and commentaries in AHRQ’s WebM&M (Morbidity
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_8-program-evaluation-speaker-notes.pdf
July 01, 2023 - Hospital AIM
Team
Leads
SPPC‐II
Growing Interest in Severe Maternal Morbidity (SMM)
□ Calls by … clinical practice
7
SCRIPT
There is growing interest in measuring and addressing severe maternal morbidity … Links:
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/severe-
morbidity-ICD.htm
https … ://www.cdc.gov/reproductivehealth
Hospital AIM
Team
Leads
SPPC‐II
Trends in Severe Maternal Morbidity … • Severe morbidity during delivery hospitalizations more than doubled during
1993‐2014, with the
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_8-program-evaluation-speaker-notes.pdf
July 01, 2023 - Hospital AIM
Team
Leads
SPPC‐II
Growing Interest in Severe Maternal Morbidity (SMM)
□ Calls by … Links:
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/severe-
morbidity-ICD.htm
https … ://www.cdc.gov/reproductivehealth
Hospital AIM
Team
Leads
SPPC‐II
Trends in Severe Maternal Morbidity … During Delivery
Hospitalizations: United States,1993‐2014
□ Severe morbidity during
delivery hospitalizations … • Severe morbidity during delivery hospitalizations more than doubled during
1993‐2014, with the
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-final-es.pdf
September 01, 2019 - Disparities
Trends in Quality
Trends in Person-Centered Care
Importance of Person-Centered Care
Morbidity … Health Provider Checking Medication
Trends in Care Coordination
Importance of Care Coordination
Morbidity … Stays Involving Opioids
Suicide Deaths
Trends in Healthy Living
Importance of Healthy Living
Morbidity … Semisynthetic Opioids and Overdose Deaths Involving Synthetic Opioids Other Than Methadone
Maternal Morbidity … and Mortality
Maternal Morbidity and Mortality Measures
Cesarean Deliveries Among Low-Risk First Births
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ce.effectivehealthcare.ahrq.gov/news/psnet.html
April 01, 2024 - Women Should Not Die Giving Life": The lived experiences of Black women diagnosed with severe maternal morbidity … publications in PSNet's current issue or access recent cases and commentaries in AHRQ's WebM&M (Morbidity
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_8_program-evaluation.pptx
July 01, 2023 - 9.2000000000000011 5.5 0.1 15.5 11 6.6 14.5
Percent of deaths
Growing Interest in Severe Maternal Morbidity … Links:
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/severe-morbidity-ICD.htm
https … https://saferbirth.org/wp-content/uploads/AIMData_SMMGuide_5CR_042922.pdf
8
Trends in Severe Maternal Morbidity … During Delivery Hospitalizations: United States,1993-2014
Severe morbidity during delivery hospitalizations … Severe morbidity during delivery hospitalizations more than doubled during 1993-2014, with the increase
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-final-es-cs061721.pdf
December 01, 2020 - Healthcare
Trends in Quality
Trends in Person-Centered Care
Importance of Person-Centered Care
Morbidity … Quality Measures by Setting of Care
Trends in Care Coordination
Importance of Care Coordination
Morbidity … Coordination Quality Measures by Topic Areas
Trends in Affordable Care
Importance of Affordable Care
Morbidity … Quality Measures by Sub-Areas
Trends in Effective Treatment
Importance of Effective Treatment
Morbidity … Effective Treatment Measures by Topic Areas
Trends in Healthy Living
Importance of Healthy Living
Morbidity
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_8_program-evaluation.pptx
July 01, 2023 - 9.2000000000000011 5.5 0.1 15.5 11 6.6 14.5
Percent of deaths
Growing interest in Severe Maternal Morbidity … AIM Team
Leads
SPPC-II
SCRIPT
There is growing interest in measuring and addressing severe maternal morbidity—or … Links:
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/severe-morbidity-ICD.htm
https … During Delivery Hospitalizations: United States,1993-2014
Severe morbidity during delivery hospitalizations … Severe morbidity during delivery hospitalizations more than doubled during 1993-2014, with the increase