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