´óÏóÊÓƵ

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:
´óÏóÊÓƵ
5600 Fishers Lane
Rockville, MD 20857

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 ´óÏóÊÓƵ (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 ´óÏóÊÓƵor 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 ´óÏóÊÓƵand 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 ´óÏóÊÓƵto reprint or translate this product. Anyone wanting to reproduce this product for sale must contact ´óÏóÊÓƵfor 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: ´óÏóÊÓƵ; September 2021. ´óÏóÊÓƵPublication No. 20(21)-0040-6-EF.