Safety and Quality in Maternity Care
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Transcript of Safety and Quality in Maternity Care
Safety and Quality in Maternity Care Denise Boulter
Midwife ConsultantPublic Health Agency
How safe is the health service?
What we aspire to What we sometimes get
How Hazardous Is Health Care? (Leape)
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1 10 100 1,000 10,000 100,000 1,000,000 10,000,000
Number of encounters for each fatality
Tota
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REGULATEDDANGEROUS(>1/1000)
ULTRA-SAFE(<1/100K)
HealthCare
Mountain Climbing
Bungee Jumping
Driving
Chemical Manufacturing
Chartered Flights
Scheduled Airlines
European Railroads
Nuclear Power
How Hazardous is Maternity Care 25,000 births Perinatal mortality lowest for 10 yearsMaternal death very uncommonHowever!!!!!Approximately 20 Serious Adverse Incidents
reportedOver 150 Complaints regarding maternity services 2012 NHS compensation bill exceeded £1
billion pounds 20% all claims are maternity 49% payout is for
maternity
Public Health Agency FunctionsHealth Protection
surveillance; health care infection; patient safety; patient experience, emergency planning; pandemic ‘flu
Health Improvement Inequalities; public awareness; local interventions;
partnerships; user involvement Commissioning & Screening
Regional & local commissioning; public health priorities; wider influence; screening services
Research & Development
PHA Commissioning RolePHA
Provide high quality independent professional and public health advice to support commissioning
Lead on commissioning and service improvement of agreed areas of work
Regional BoardMust consult PHA and have due regard for advice or
information providedMust not publish a commissioning plan without PHA
approvalLCGs
Legislation requires LCGs to work in collaboration with PHA
“New Rules” for Health Care
Safety as a system propertyThe need for transparency and effective reporting
– information a tool rather than a trial.Testing the systems and the staff More rapid response when things go wrongTracking and providing feedback about adverse
eventsIncreased Cooperation
Issues There are serious problems in quality
Between the health care we have and the care we could have, lies not just a gap but a chasm.
The problems come from poor systems…not bad peopleThe question is why have we not sorted it to
date? We can fix it… but it will require changes
The First Law of Improvement
Every system is perfectly designed to achieve exactly the results it gets.
Ingredients Practice
Evidence basedCare Pathways Consistent
processesEducation &
training
People Person Centred
ServiceSafety Forum Support and challenge Education and training
People You are the key ingredient in making
patients safe.What can I do?
Communicate Report incidents Open and honest culture Contribute to risk assessments and audit Put safety top of your priorities – ‘ do no harmAsk for help Don’t take short cuts Legible writing
PrioritiesStrategy Implementation / Development
Maternity Strategy for Northern IrelandMidwifery 2020
Maternity Quality Improvement groupMaternity Hand Held Record Regional Learning Letters
When it goes wrong Death of Savita HallappanavarFailure to recognise she was ill
The most basic means of identifying any patients at risk of clinical deterioration is to observe the patient and regularly monitor and track her clinical observations
Lack of learning from previous similar case2008 Tanya Mc Cabe
The hospital should invest in a physiological observation track and trigger system that promotes the early recognition of patient deterioration and appropriate intervention
Serious Adverse IncidentsDefinition of an adverse incident:
‘Any event or circumstances that could have or did lead to harm, loss or damage to people, property, environment or reputation’. arising during the course of the business of a HSC organisation / Special Agency or commissioned service
SAI criteria
Serious injury to, or the unexpected/unexplained death of: a service user a staff member in the course of their work a member of the public whilst visiting a HSC facility.
Any death of a child (up to eighteenth birthday) in a hospital setting. Unexpected serious risk to a service user and/or staff member and/or member of the public Unexpected or significant threat to provide service and/or maintain business continuity Serious self-harm or serious assault (including homicide and sexual assaults) by a service user, a member of staff or a member
of the public within a healthcare facility Suspected suicide of a service user known to Mental Health services (including Child and Adolescent Mental Health Services,
(CAMHS) and Learning Disability (LD) within the last year. Serious self-harm / serious assault (including homicide and sexual assaults) by a service user in the community who is known
to mental health services (including CAMHS) or learning disability services within the last year. on themself on other service users, on staff or on members of the public
Serious incidents of public interest or concern relating to: any of the criteria above theft, fraud, information breaches or data losses a member of HSC staff or independent practitioner
QUALITY, SAFETY AND EXPERIENCE
SAFETY QUALITY ALERT TEAM
SERIOUS ADVERSE INCIDENTS COMPLAINTS
Myths The perfection myth – if we all try hard
enough we will not make any mistakes
The punishment myth – of we punish people when they make mistakes they will make fewer.
The reality We all make errors, no matter how much training and experience we process, or how
motivated we are to do right.
To err is humanTo cover up is unforgivableTo fail to learn is inexcusable
The Message
ALWAYSEnsure that the urgent doesn’t
crowd out the important