Issue Brief 6
Contents
Introduction
The Contribution of Diagnostic Error to Maternal Mortality and Severe Maternal Morbidity
Rationale for Improvement Tools
Implementing Hospitalwide Safety Bundles
Addressing Implicit Bias, Structural Barriers, and Social Determinants of Health
Healthcare Simulation To Characterize, Design, and Change Processes
Research Agenda
Conclusions and Next Steps
References
Prepared for:
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
www.ahrq.gov
Contract Number HHSP233201500022I/75P00119F37006
Prepared by:
Komal Bajaj, M.D., M.S.-H.P.Ed.
NYC Health + Hospitals/Jacobi
NYC Health + Hospitals, Albert Einstein College of Medicine
Ariel de Roche, M.S., CLC
Birth and Postpartum Doula
Dena Goffman, M.D.
New York-Presbyterian/Columbia University Irving Medical Center
This project was funded under contract number HHSP233201500022I/75P00119F37006 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this document’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this product as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this product.
Public Availability Notice. This product is made publicly available by AHRQ and may be used and reprinted without permission in the United States for noncommercial purposes, unless materials are clearly noted as copyrighted in the document. No one may reproduce copyrighted materials without the permission of the copyright holders. Users outside the United States must get permission from AHRQ to reprint or translate this product. Anyone wanting to reproduce this product for sale must contact AHRQ for permission.
Citation of the source is appreciated.
Suggested Citation: Bajaj K, de Roche A, Goffman D. The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. AHRQ Publication No. 20(21)-0040-6-EF.
