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Progress in Patient Safety and Quality in Maternal–Fetal Medicine

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Obstetrics & Gynecology".

Deadline for manuscript submissions: 31 October 2025 | Viewed by 9057

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Special Issue Editor

Dr. Samuel T. Bauer

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Guest Editor

Department of Obstetrics and Gynecology, School of Medicine, Duke University, Durham, NC, USA
Interests: maternal–fetal medicine; maternity; fetus; pregnancy; patient safety

Special Issue Information

Dear Colleagues,

This Special Issue aims to compile original research and review articles focused on enhancing patient safety and clincial quality improvement relevant to pregnancy and postpartum care. We welcome submissions on a wide variety of topics related to clinical quality and safety, including but not limited to:

Medical error;
Diagnostic error;
Adverse events;
Disclosure and reporting;
Model for improvement;
Implementation science;
Health equity;
Social drivers of health;
Team building and communication;
Care handoffs;
Simulation and drills.

This Special Issue is particularly interested in articles that highlight clinical quality improvement projects and initiatives aimed at enhancing patient safety and quality within maternal–fetal medicine. Authors are encouraged to submit their research and findings related to these topics to contribute to the advancement of patient safety and quality.

Dr. Samuel T. Bauer
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

maternal–fetal medicine
pregnancy
postpartum
medical error
maternity
fetus

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Published Papers (7 papers)

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Research

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17 pages, 1740 KiB

Open AccessArticle

Development of a Risk Score for the Prediction and Management of Pre-Eclampsia in Low-Resource Settings

by Victor Bogdan Buciu, Dorin Novacescu, Flavia Zara, Denis Mihai Șerban, Larisa Tomescu, Sebastian Ciurescu, Sebastian Olariu, Marina Rakitovan, Antonia Armega-Anghelescu, Alexandu Cristian Cindrea, Mihai Ionac and Veronica-Daniela Chiriac

J. Clin. Med. 2025, 14(10), 3398; https://doi.org/10.3390/jcm14103398 - 13 May 2025

Viewed by 420

Abstract

Background: Pre-eclampsia is a significant hypertensive disorder affecting 2–8% of pregnancies globally, significantly contributing to maternal/perinatal deaths. Early identification of at-risk patients is crucial for reducing these mortalities, yet first-trimester screening remains inaccessible in many low-resource settings. This study aims to develop a second-trimester risk stratification model based on clinical parameters to assist in managing pre-eclampsia in diverse healthcare contexts. Methods: This retrospective cohort study analyzed medical records from 700 pregnancies (350 with preeclampsia, 350 controls) between January 2021 and August 2024 at a tertiary medical center in western Romania. Sample size was calculated to achieve 90% power with α = 0.05 for detecting clinically significant differences between groups. Data analysis focused on clinical variables such as maternal age, hypertension, diabetes, and socioeconomic factors. A scoring model was developed using logistic regression and validated for predictive accuracy using ROC curve analysis, with AUC as the primary metric. Calibration was assessed using the Hosmer–Lemeshow test. Results: The risk stratification model demonstrated an AUC of 0.91 (95% CI: 0.88–0.94), indicating high discriminative capability. The model showed good calibration (p = 0.78). Sensitivity was 74.4%, and specificity reached 97.8%. Patients were categorized into low (0–4 points), moderate (5–7 points), and high-risk (≥8 points) groups based on optimized cut-off values. High-risk patients showed significantly higher rates of adverse outcomes, including eclampsia (12.3% vs. 0% in low-risk, p < 0.001) and HELLP syndrome (8.7% vs. 0.5% in low-risk, p < 0.001). Neonates born to high-risk mothers had lower birth weight (mean difference: 486 g, p < 0.001), smaller head circumference (mean difference: 2.3 cm, p < 0.001), and lower APGAR scores (median difference: 2 points, p < 0.001). Conclusions: This novel model offers a practical second-trimester risk assessment tool that leverages routine clinical data available after 20 weeks of gestation. It facilitates targeted care and resource allocation, particularly benefiting settings lacking early screening access. Implementation of risk-stratified management protocols could significantly improve maternal and neonatal outcomes in diverse healthcare environments. Full article

(This article belongs to the Special Issue Progress in Patient Safety and Quality in Maternal–Fetal Medicine)

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19 pages, 3059 KiB

Open AccessArticle

Quantitative Approach to Quality Review of Prenatal Ultrasound Examinations: Incomplete Detailed Fetal Anatomy Exams

by C. Andrew Combs, Olaide Ashimi Balogun, Jeroen Vanderhoeven and Sushma Amara

J. Clin. Med. 2025, 14(10), 3356; https://doi.org/10.3390/jcm14103356 - 12 May 2025

Viewed by 228

Abstract

Background/Objectives: It is challenging to obtain all the required views for a fetal anatomy ultrasound examination, so exams are often incomplete. Our objective was to develop and demonstrate quantitative methods to assess the overall rate of incomplete exams for an ultrasound practice and for individual examiners. Methods: We performed a retrospective quality review of all detailed fetal anatomy exams at seven maternal–fetal medicine practices in 2024 with singleton pregnancies and cardiac activity present. The exams were considered incomplete if any of the 36 required anatomy views were reported as inadequate. The analysis focused on exams at a gestational age (GA) of 18.0 to 23.9 weeks. The rates of incomplete exams were tabulated across practices and for individual sonographers and physicians. Multivariable logistic regression was used to adjust for known covariates. Results: In total, 15,723 detailed fetal anatomy exams were performed at 18.0–23.9 weeks of gestation. Incomplete exams were significantly more common with maternal obesity, prior cesarean, maternal age < 35 years and GA < 19 weeks. There were significant between-practice differences in the rate of incomplete exams, varying from 1% to 53%. Incomplete exams had a median of four inadequate views (interquartile range 2–7). Practices also varied significantly in the rate of missing measurements for nuchal fold (0 to 9%) and nose bone length (11–100%). There were significant between-individual differences in the rate of incomplete exams. The tabulation of specific views showed some individuals with very high rates of inadequate views of certain elements. Conclusions: For some practices, there is a need for practice-wide quality improvement to increase the rate of measurement of the nuchal fold and nose bone. For selected individuals, the tabulation of which anatomy elements were inadequate can identify areas for targeted education or mentorship. We suggest strategies and software enhancements that may reduce the rate of incomplete exams. Sample data and statistical analysis scripts are provided for those who wish to adopt these methods to review their own data. Full article

(This article belongs to the Special Issue Progress in Patient Safety and Quality in Maternal–Fetal Medicine)

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14 pages, 442 KiB

Open AccessArticle

Quantitative Approach to Quality Review of Prenatal Ultrasound Examinations: Estimated Fetal Weight and Fetal Sex

by C. Andrew Combs, Ryan C. Lee, Sarah Y. Lee, Sushma Amara and Olaide Ashimi Balogun

J. Clin. Med. 2024, 13(22), 6895; https://doi.org/10.3390/jcm13226895 - 16 Nov 2024

Cited by 1 | Viewed by 1085

Abstract

Background/Objectives: Systematic quality review of ultrasound exams is recommended to ensure accurate diagnosis. Our primary objectives were to develop a quantitative method for quality review of estimated fetal weight (EFW) and to assess the accuracy of EFW for an entire practice and for individual personnel. A secondary objective was to evaluate the accuracy of fetal sex determination. Methods: This is a retrospective cohort study. Eligible ultrasound exams included singleton pregnancies with live birth and known birth weight (BW). A published method was used to predict BW from EFW for exams with ultrasound-to-delivery intervals of up to 12 weeks. Mean error and median absolute error (AE) were compared between different personnel. Image audits were performed for exams with AE > 30% and exams with reported fetal sex different than newborn sex. Results: We analyzed 1938 exams from 890 patients. In the last exam before birth, the median AE was 5.9%, and the predicted BW was within ±20% of the actual BW in 97.2% of patients. AE was >30% in 28 exams (1.4%); image audit found correct caliper placement in all 28. Only two patients (0.2%) had AE > 30% on the last exam before birth. One sonographer systematically over-measured head and abdominal circumferences, leading to EFWs that were overestimated. Reported fetal sex differed from newborn sex in seven exams (0.4%) and five patients (0.6%). Images in four of these patients were annotated with the correct fetal sex, but a clerical error was made in the report. In one patient, an unclear image was labeled “probably female”, but the newborn was male. Conclusions: The accuracy of EFW in this practice was similar to literature reports. The quantitative analysis identified a sonographer with outlier measurements. Time-consuming image audits could be focused on a small number of exams with large errors. We suggest some enhancements to ultrasound reporting software that may help to reduce clerical errors. We provide tools to help other practices perform similar quality reviews. Full article

(This article belongs to the Special Issue Progress in Patient Safety and Quality in Maternal–Fetal Medicine)

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13 pages, 3011 KiB

Open AccessArticle

Quantitative Approach to Quality Review of Prenatal Ultrasound Examinations: Fetal Biometry

by C. Andrew Combs, Sushma Amara, Carolyn Kline, Olaide Ashimi Balogun and Zachary S. Bowman

J. Clin. Med. 2024, 13(16), 4860; https://doi.org/10.3390/jcm13164860 - 17 Aug 2024

Cited by 3 | Viewed by 1239

Abstract

Background/Objectives: To evaluate the quality of an ultrasound practice, both large-scale and focused audits are recommended by professional organizations, but such audits can be time-consuming, inefficient, and expensive. Our objective was to develop a time-efficient, quantitative, objective, large-scale method to evaluate fetal biometry measurements for an entire practice, combined with a process for focused image review for personnel whose measurements are outliers. Methods: Ultrasound exam data for a full year are exported from commercial ultrasound reporting software to a statistical package. Fetal biometry measurements are converted to z-scores to standardize across gestational ages. For a large-scale audit, sonographer mean z-scores are compared using analysis of variance (ANOVA) with Scheffe multiple comparisons test. A focused image review is performed on a random sample of exams for sonographers whose mean z-scores differ significantly from the practice mean. A similar large-scale audit is performed, comparing physician mean z-scores. Results: Using fetal abdominal circumference measurements as an example, significant differences between sonographer mean z-scores are readily identified by the ANOVA and Scheffe test. A method is described for the blinded image audit of sonographers with outlier mean z-scores. Examples are also given for the identification and interpretation of several types of systematic errors that are unlikely to be detectable by image review, including z-scores with large or small standard deviations and physicians with outlier mean z-scores. Conclusions: The large-scale quantitative analysis provides an overview of the biometry measurements of all the sonographers and physicians in a practice, so that image audits can be focused on those whose measurements are outliers. The analysis takes little time to perform after initial development and avoids the time, complexity, and expense of auditing providers whose measurements fall within the expected range. We encourage commercial software developers to include tools in their ultrasound reporting software to facilitate such quantitative reviews. Full article

(This article belongs to the Special Issue Progress in Patient Safety and Quality in Maternal–Fetal Medicine)

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10 pages, 1445 KiB

Open AccessArticle

Adherence to Labor Arrest and Failed Induction of Labor Guidelines: The Impact of a Quality-Improvement Educational Intervention

by Jennifer J. M. Cate, Christopher K. Arkfeld, Meagan Campol, Katherine H. Campbell, Christian M. Pettker and Jessica L. Illuzzi

J. Clin. Med. 2024, 13(16), 4720; https://doi.org/10.3390/jcm13164720 - 12 Aug 2024

Viewed by 1354

Abstract

Background/Objective: To evaluate adherence to labor arrest and failed induction of labor (IOL) criteria in nulliparous, term, singleton, and vertex (NTSV) cesarean deliveries at an academic medical center and to measure the impact of a quality-improvement educational initiative that focused on obstetric provider education of modern labor arrest and failed IOL criteria. Methods: This is a retrospective cohort study using electronic health record (EHR) data with a pre- (1 September 2018–30 September 2019) and post-intervention (1 October 2019–31 March 2020) study design of all NTSV cesarean deliveries for labor arrest or failed IOL performed at an academic medical center in the northeastern United States. The quality-improvement educational intervention consisted of the distribution of educational pocket cards outlining modern labor arrest and failed IOL criteria to obstetric providers. Outcomes included adherence to labor arrest and failed IOL criteria pre- and post-intervention with secondary outcomes evaluating adherence by provider type (Maternal–Fetal Medicine (MFM) or generalist obstetrician). Descriptive and bivariate statistics were used in the analysis. Results: Pre-intervention, 272 NTSV cesarean deliveries were performed for labor arrest or failed IOL versus 92 post-intervention. Adherence improved post-intervention amongst failed IOL (OR 6.5, CI 1.8–23.8), first-stage arrest (OR 4.5, CI 2.2–10.8) and second-stage arrest (OR 3.7, CI 1.5–9.4). When comparing provider type, MFM physicians were more likely to be adherent to labor arrest and failed IOL criteria compared to generalist obstetricians pre-intervention (OR 3.1, CI 1.7–5.5); however, post-intervention, there was no longer a difference in adherence (OR 3.3, CI 0.9–12.3). Conclusions: Adherence to labor arrest criteria was suboptimal in the pre-intervention period; however, a targeted quality-improvement educational intervention improved adherence rates to labor arrest and failed IOL criteria among obstetric providers. Full article

(This article belongs to the Special Issue Progress in Patient Safety and Quality in Maternal–Fetal Medicine)

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Review

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11 pages, 587 KiB

Open AccessReview

Diagnostic Errors in Obstetric Morbidity and Mortality: Methods for and Challenges in Seeking Diagnostic Excellence

by Nicole M. Krenitsky, India Perez-Urbano and Dena Goffman

J. Clin. Med. 2024, 13(14), 4245; https://doi.org/10.3390/jcm13144245 - 20 Jul 2024

Cited by 1 | Viewed by 1516

Abstract

Pregnancy-related morbidity and mortality remain high across the United States, with the majority of deaths being deemed preventable. Misdiagnosis and delay in diagnosis are thought to be significant contributors to preventable harm. These diagnostic errors in obstetrics are understudied. Presented here are five selected research methods to ascertain the rates of and harm associated with diagnostic errors and the pros and cons of each. These methodologies include clinicopathologic autopsy studies, retrospective chart reviews based on clinical criteria, obstetric simulations, pregnancy-related harm case reviews, and malpractice and administrative claim database research. We then present a framework for a future study of diagnostic errors and the pursuit of diagnostic excellence in obstetrics: (1) defining and capturing diagnostic errors, (2) targeting bias in diagnostic processes, (3) implementing and monitoring safety bundles, (4) leveraging electronic health record triggers for case reviews, (5) improving diagnostic skills via simulation training, and (6) publishing error rates and reduction strategies. Evaluation of the effectiveness of this framework to ascertain diagnostic error rates, as well as its impact on patient outcomes, is required. Full article

(This article belongs to the Special Issue Progress in Patient Safety and Quality in Maternal–Fetal Medicine)

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Other

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13 pages, 1672 KiB

Open AccessPerspective

Severe Hypertension in Pregnancy: Progress Made and Future Directions for Patient Safety, Quality Improvement, and Implementation of a Patient Safety Bundle

by Alissa Prior, Isabel Taylor, Kelly S. Gibson and Christie Allen

J. Clin. Med. 2024, 13(17), 4973; https://doi.org/10.3390/jcm13174973 - 23 Aug 2024

Cited by 2 | Viewed by 2372

Abstract

Hypertensive disorders of pregnancy account for approximately 5% of pregnancy-related deaths in the United States and are one of the leading causes of maternal morbidity. Focus on improving patient outcomes in the setting of hypertensive disorders of pregnancy has increased in recent years, and quality improvement initiatives have been implemented across the United States. This paper discusses patient safety and quality initiatives for hypertensive disorders of pregnancy, with an emphasis on progress made and a patient safety tool: the Alliance for Innovation on Maternal Health’s Severe Hypertension in Pregnancy patient safety bundle. Future patient safety and quality directions for the treatment of hypertensive disorders of pregnancy will be reviewed. Full article

(This article belongs to the Special Issue Progress in Patient Safety and Quality in Maternal–Fetal Medicine)

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