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Towards safer maternity care NPSA initiatives

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Safety First highlights key areas for improvement in current ... To busy beavering away to notice problems. Coping with service. Learning ends with the accident ... – PowerPoint PPT presentation

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Title: Towards safer maternity care NPSA initiatives


1
Towards safer maternity careNPSA initiatives
  • Professor James Walker,
  • Professor Obstetrics and Gynaecology, Leeds
  • Clinical Specialty Adviser (NPSA)

2
Safety First
Safety First highlights key areas for improvement
in current safety reporting systems in the NHS.
These include
  • Simplifying and encouraging reporting
  • More rapid reporting
  • Capturing risky situations
  • Using patient safety data to inform
  • learning and action locally
  • analysis, learning and feedback

3
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

4
"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

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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

7
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

8
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

9
Solution
We cant change the human condition, but we can
change the conditions under which humans
work James Reasons
10
NICE guidelines
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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

14
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)

15
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

16
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

17
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

18
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

19
The IHI has recognises that
  • Sound science is known
  • Application unreliable
  • Evidence-based guidelines exist
  • The challenge is to ensure application

20
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!

21
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

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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

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26
We all need to take responsibility to learn from
our mistakes and implement changes to try and
stop them happening again ..
27
Royal College ofObstetricians andGynaecologists
Setting standards to improve womens health
Risk Management and Medico-Legal Issues In
Womens Health Joint RCOG/ENTER Meeting
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