Towards safer maternity care NPSA initiatives

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Towards safer maternity careNPSA initiatives

• Professor James Walker,
• Professor Obstetrics and Gynaecology, Leeds
• Clinical Specialty Adviser (NPSA)

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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

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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

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"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

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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

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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

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

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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)

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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

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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

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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

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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

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The IHI has recognises that

• Sound science is known
• Application unreliable
• Evidence-based guidelines exist
• The challenge is to ensure application

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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!

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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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We all need to take responsibility to learn from
our mistakes and implement changes to try and
stop them happening again ..
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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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