OPSC Review of Maternal and Perinatal Events: Lessons from Oregon’s Patient Safety Reporting Program

Learning
Written By Oregon Patient Safety Commission

The Oregon Patient Safety Commission (OPSC) reviewed adverse event reports involving a mother, fetus, and/or neonate submitted to the Patient Safety Reporting Program (PSRP) to share some of what Oregon hospitals have learned about the causes of these events.

Key Takeaways

  • Maternal and perinatal adverse events happen all over the world, including in Oregon.

  • Many of the adverse events reported involved care delays, including failure to recognize a mother or baby’s changing condition during a long labor, a misinterpretation of or lack of communication about questionable fetal heart tracings, and a breakdown of communication between providers and staff both within and across units, specifically in emergent situations.

Read the full review to learn more: OPSC Review of Maternal and Perinatal Events: Lessons from Oregon’s Patient Safety Reporting Program

Oregon Patient Safety Commission
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