Overall, more research is needed to reduce maternal morbidity and mortality,44 including the contribution of diagnostic error to the care and treatment of birthing people. Through a 2014 cooperative agreement, Alliance for Innovation in Maternity Care, the Health Resources and Services Administration and the American College of Obstetricians and Gynecologists have advocated for solutions to maternal morbidity and mortality. They propose the “4 R’s”:
- Readiness (institution’s resources, protocols, and procedures).
- Recognition and Prevention (assessment, measurement, and management).
- Response (treatment).
- Reporting and Systems Learning (communication, debrief, and review).23
In 2021, they included a fifth domain, Respectful Care (patients’ right to be informed, educated, and supported), as it is critical for delivering safe, patient-centered, high-quality care.45
The domains of the “5 R’s” were used as an outline for a proposed research agenda (Table 1), building on existing work related to maternal hemorrhage during childbirth and through the immediate postpartum period as a primary example. This approach and agenda can be applied to other causes of maternal morbidity and mortality, such as sepsis and hypertensive disorders in pregnancy.
It is imperative to include a diagnostic safety lens to improvement efforts targeting maternal health. It will be crucial to understand, define, and measure diagnostic error and performance within this field to further optimize care.17 This agenda presents an opportunity to integrate ongoing diagnostic safety efforts and approaches into maternal health initiatives.
Table 1. Proposed Research Agenda To Understand and Improve the Contribution of Diagnostic Safety to Maternal Morbidity and Mortality
|Research Gap||Justification||Proposed Research*|
|Readiness||Education and Training Modalities||It is unclear which training models or modalities have the greatest impact on increased quality and safety.||Evaluate trainings and training modalities associated with improved diagnostic safety in [maternal hemorrhage], such as simulation.43,46|
|It is unclear which combination of trainings increase quality and safety.||Evaluate combinations of trainings and their effects on improving [maternal hemorrhage] quality and safety.47|
|Deliberate practice to maintain skills is imperative to quality perinatal care.||Explore the frequency of experiential trainings, including simulation, required to maintain skills.|
|Recognition and Prevention||Factors Contributing to Diagnostic Error||There is limited understanding of contribution of diagnostic error to diagnosis or escalation of care.||Determine incidence of diagnostic error in [maternal hemorrhage] recognition.12|
|Identification of risk factors is important to increase diagnostic accuracy.||Determine demographic and clinical factors associated with diagnostic delay during [maternal hemorrhage].15|
|Cognitive and system errors are major contributing factors to diagnostic error.||Identify provider factors, including bias, that contribute to diagnostic error, including missed or delayed diagnosis.19|
|System errors are major contributing factors to diagnostic error.||Identify institutional factors that contribute to diagnostic error, including policies and cultural factors.48|
|Assessments||Standardizing methods for determining risk will improve recognition and escalation efforts.||Identify the most sensitive markers for [maternal hemorrhage], e.g., quantitative blood loss, early warning signs.|
|Develop and validate risk assessments that promote reliable and safe diagnostic practices.|
|Response||Cognitive Errors||Significant evidence exists to suggest that providers may be affected by underlying cognitive errors.||Determine impact of various cognitive errors (e.g., implicit bias, anchoring, confirmation, knowledge synthesis) on diagnostic error in maternal hemorrhage care.|
|Information Technology||Efficient health information technology can improve patient safety.||Evaluate how health information technology, such as electronic health records, contributes to diagnostic errors.|
|Identify solutions based on health information technology that are associated with improved diagnostic safety.|
|Treatment||Standardizing treatment can reduce cognitive error.||Build on existing best practices to include benchmarks for treatment, including medication administration of [maternal hemorrhage].|
|Reviewing timeliness of interventions can provide more direct guidance for treatment.||Evaluate evidence of improvement in care if specific treatment is implemented in a specific timeframe.|
|Teamwork||Objective triggers for automatic assembly of healthcare team are key to effective treatment.||Explore teamwork factors associated with prompt response to [maternal hemorrhage].|
|Explore which factors promote real-time quantification and discussion of blood loss.|
|Evaluate the impact of experiential learning, such as simulation, on teamwork culture and relationships.|
|Reporting and Systems Learning||Data Collection||A need exists for standardized documentation and reporting of events.||Collect standardized institution-based reports of [maternal hemorrhage].|
|Iterative processes of review and refining of quality and safety measures are needed.||Identify diagnostic safety issues through case review using the Safer Dx framework.16,17|
|Reviewing trends at a national/State level can affect care at the institutional level.||Synthesize learning from State/national repositories.|
|Learning from when events go well (Safety-II) is crucial to improving systems.49||Collect and synthesize attributes of [maternal hemorrhage] where a diagnostic safety event did not occur.|
|Apply lessons learned from trends and improvements in morbidity and mortality due to various comorbidities outside of pregnancy to obstetrics.|
|Insurance Reimbursement||Extended care may affect diagnostic safety specifically during the postpartum period.||Explore the impact of bundled payment of postpartum coverage on diagnostic safety events.10|
|Respectful Care||Patient Communication||Patients and their families deserve to be informed throughout their care.||Evaluate best way to engage patients and families in preventing diagnostic safety events.|
|Evaluate best way to disclose diagnostic safety events to patients and families.|
|Evaluate best ways to engage patients and families in diagnostic safety event mitigation and reporting.|
* The proposed research agenda can be applied to understand and improve the contribution of diagnostic safety to various causes of maternal morbidity and mortality. It builds on existing works (completed or in progress) to identify notable gaps that should be prioritized for advocacy and funding.