Towards safer maternity careNPSA initiatives

Professor James Walker,

Professor Obstetrics and Gynaecology, Leeds

Clinical Specialty Adviser (NPSA)

Safety First

• Simplifying and encouraging reporting

• More rapid reporting • Capturing risky situations • Using patient safety data to inform

– learning and action locally– analysis, learning and feedback

Safety First highlights key areas for improvement in current safety reporting systems in the NHS. These include:

Safer Practice in Intrapartum Care (SPIPC)

• Working with the NRLS (National Reporting and Learning System)

• Improving/standardising incident reporting• Develop obstetric care “bundles”

– Implementing and testing • Improving and Standardising training• Setting up systems of implementation and evaluation

– Standard data collection

"First, Do No Harm"

• Most practitioners are caring individuals– Highly skilled– Highly trained

• We all work hard for the common good– No time to report – No time to attend review meetings– Beavering away

Problems for the Beaver• To busy beavering away to notice problems

– Coping with service

• Learning ends with the accident– No audit trail of problems or near miss inquiries– No “system” memory

• No recommendations/guideline development– No skill drills

• The system is inherently dangerous– Continued accidents

Improving Reporting• Working with the NRLS

– Improving detection of trends• Highlighting clusters• Looking at the good as well as the bad

– Improved interrogation of NRLS data• Coding/trigger lists

– Develop direct access for RCOG and RCM • Share the higher priority incidents

– Across all maternity services– Gain rapid feedback– Instigate alerts/interventions

– Provide wider learning for the NPSA

Incident analysis

• Link with the SHAs– Correlate CEMACH data– Encourage SUI– Improve safety culture

• Encourage local analysis– Standard SUI/RCA analysis– Allow aggregate RCA– Increase information available to central agencies

“We can’t change the human condition, but we can change the conditions under which humans work”

James Reasons

Solution

NICE guidelines

Safer Practice in Intra-partum Care

• Find solutions to all problems

– Not reinvent the wheel!

– Utilise what is out there

• Developing two obstetric “care bundles”

– A ”care bundle" is a

• group of interventions related to a disease process • when executed together they result in better outcomes

than when implemented individually– They must be adhered to and signed off

Safer Practice in Intra-partum Care • Obstetric “care bundles”

– Aimed at improving patient safety in intrapartum care• Placenta Previa in Previous Caesarean Section• Intrapartum CTG assessment

• Look for pilot/development sites (10)– keen and less keen sites, big and small

• Develop implementation toolkits• Develop evaluation toolkits

• One-two year time scale• Follow on from there (RCOG/RCM buy-in)

PP in Prev CS care bundle - why?

• Relatively rare event• Associated with around 50% of Hysterectomies

– Incidence around 1/30• Associated with most of the maternal deaths from

haemorrhage– Incidence around 1/300

• Problems related to lack of preparation– Awareness

PP/CS care bundle

• Where to start?– Guidance for diagnosis – CEMACH– Bundle starts after diagnosis

• Where to stop?– Start of procedure

• How does it fit into the whole?– Evidence/guidelines/other bundles

• What else is required?– Implementation/training

EFM care bundle - why?

• Obstetric claims account for over 70% of all NHS litigation expenses with an average cost of cerebral palsy cases of £1.5m.

• Current estimate that obstetric claims amount to £400m of total £600m projected NHS costs.

• Over 85% of CP cases are associated with abnormalities of fetal heart monitoring.

Source: Learning from litigation: an analysis of claims for clinical negligence – Vincent, Davy, Esmail, Neale, Elstein, Cozens, Walshe – August 2004

EFM care bundle

• Where to start?– Decision to use– Labeling of woman

• Where to stop?– After EFM assessment

• How does it fit into the whole?– Evidence/guidelines/other bundles

• What else is required?– Implementation/training

The IHI has recognises that:

• Sound science is known

• Application unreliable

• Evidence-based guidelines exist

• The challenge is to ensure application

Reasons for Evidence Committee

• What evidence can be used?– Best evidence– Believable– Acceptable– Pragmatic

• Ranking of evidence• We need to develop complete bundle

– All components covered with some evidence!

The Simulation and Fire drill Evaluation (SaFE)

• Learning points– multiprofessional training packages – implemented both locally and centrally– generally well received by healthcare staff

• Benefits of local training – Work with local protocols and equipment.– More cost-effective – Helps clinical staff to re-attend to update

Audit implementation and outcome

• Audit PP/CS bundle assessment– Has the bundle been followed? – Have the plans laid out been followed?– If either were not, why not

• Outcome assessment – Audit of hysterectomy– Audit of blood loss– Admission to ICU– Maternal Death

We all need to take responsibility to learn from our mistakes and implement changes to

try and stop them happening again …..

Royal College ofObstetricians andGynaecologists

Setting standards to improve women’s health

Risk Management and Medico-Legal Issues In Women’s HealthJoint RCOG/ENTER Meeting

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