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Found 554 results
  1. Content Article
    The COVID-19 pandemic provides new challenges for the safety of people receiving and providing maternity care. This project, conducted in collaboration with the PROMPT Maternity Foundation and THIS.institute, involved a rapid-response consultation exercise to understand what good looks like for managing obstetric emergencies in women with suspected or confirmed COVID-19.
  2. Content Article
    Sarah Seddon's son (Thomas) was stillborn in May 2017. The lack of candour following Thomas’ death and the conduct of the serious incident investigation impacted significantly on Sarah and her family. The local investigation was followed by a Fitness to Practise (FtP) investigation where Sarah experienced how damaging, dehumanising and traumatic FtP processes can be for patients who are required to be witnesses. Here she reflects on the impact of being a witness in a Fitness to Practise (FtP) hearing had on her.
  3. Content Article
    This Postnatal Risk Assessment Matrix (PRAM) resource was developed by Dr Cindy Shawley, Quality Improvement Lead for Maternity at Hampshire Hospitals NHS Foundation Trust. The pack includes a number of monitoring and assessment tools to help keep mums and babies safe. The following two sections have been selected for the finals of the Nursing Times Awards, under the Patient Safety category: The First Hour of Care: Keeping mums and babies together (a proforma and pathway to promote normal adaptation to life) Holding your baby safely poster (as referenced in the recent National Learning Report, Neonatal collapse alongside skin-to-skin contact) Please open the attached documents to view the full PRAM resource pack as well as the two award-nominated sections that can be downloaded independently.  Many thanks to Dr Shawley for giving permission to share these important patient safety resources on the hub.
  4. Content Article
    Clinical governance is the system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical excellence will flourish. Clinical governance encompasses quality assurance, quality improvement and risk and incident management. These guidelines cover responsibilities, programme standards and performance monitoring, quality assurance, quality improvement, and risk and incident management.
  5. Content Article
    National Learning Reports offer insight and learning about recurrent patient safety risks in NHS healthcare that have been identified through HSIB investigations. They present a digest of relevant, previously investigated events, highlight recurring themes and, where appropriate, make safety recommendations. National learning reports can be used by healthcare leaders, policymakers and the public to aid their knowledge of systemic patient safety risks and the underlying contributory factors, and to inform decision making to improve patient safety. The Healthcare Safety Investigation Branch (HSIB) Summary of themes arising from HSIB maternity investigation programme report (March 2020) describes eight themes arising from the maternity investigations. Sudden unexpected postnatal collapse (SUPC) was identified as a theme for further exploration in order to highlight areas of system-wide learning. SUPC is a rare but potentially fatal event in otherwise healthy appearing term (born after 37 completed weeks) newborn babies at birth. Between April 2018 and August 2019 HSIB completed 335 maternity investigations. Of the 12 identified SUPC cases, there were 6 cases where positioning of the baby to achieve skin-to-skin contact may have contributed to SUPC. While the number of incidents found was small compared to the number of term babies who had skin-to-skin contact at birth these incidents may in future be avoided and so learning is essential.
  6. Content Article
    In this edition of the Nursing and Midwifery Council's (NMC) public newsletter, we hear from Sarah Seddon, who was a witness in a fitness to practise investigation following the tragic loss of her baby. She shares how this process felt and how she is using her personal experience to help the NMC work in a more person-centred way.
  7. Content Article
    The goal of this US-based study, published in Psychiatric Services, was to characterise racial-ethnic differences in mental health care utilisation associated with postpartum depression in a multi-ethnic cohort of Medicaid recipients. Medicaid in the United States is a federal and state program that helps with medical costs for some people with limited income and resources. Findings of the study presents evidence of low rates of postpartum depression treatment initiation and continuation, indicating barriers to care among low-income mothers; racial-ethnic disparities imply additional challenges for black women and Latinas. The presence of such disparities points to the need for clinical and institutional policies and programs to address the particular barriers to mental health care faced by black women and Latinas in the months after delivery.
  8. Content Article
    This paper, from THIS Institute, aims to describe exactly what needs to happen for maternity care to be safe by examining how interventions and context work together to nurture and sustain safe practice.
  9. Content Article
    This series of podcasts, supported by the Maternity Experience (#MatExp), is produced by Florence Wilcock. She explores different topics within maternity, aiming to ignite positive change and action.
  10. Content Article
    More women are choosing to birth at home in well-resourced countries. Concerns persist that out-of-hospital birth contributes to higher perinatal and neonatal mortality. This systematic review, published by The Lancet, and meta-analyses determines if risk of fetal or neonatal loss differs among low-risk women who begin labour intending to give birth at home compared to low-risk women intending to give birth in hospital.
  11. Content Article
    Group B Strep can be a complex topic, with some confusion about what exactly is the latest guidelines on testing, risk factors, recommended antibiotics, and the impact (if any) of GBS on homebirths, waterbirths, breastfeeding, and much more.This is why Group B Strep Support and the Royal College of Midwives (RCM) have produced an evidence-based group B Strep i-learn module.The group B Strep i-learn module focuses on the current UK guidelines for preventing group B Strep infection in newborn babies and on signs of these infections in babies. It will refresh clinician knowledge of the national guidelines, and help you tackle the FAQs you get from expectant and new parents.Follow the link below to find out how to sign up.
  12. Content Article
    Group B streptococcus (GBS) is a naturally occurring bacterium, often found in the mother’s vagina, which can be dangerous for babies during labour and immediately after birth. The mothers carry this bacterium in the birth canal without any problem to themselves. Giving antibiotics to the mother during labour reduces the incidence of GBS infection passing on to the baby (National Institute for Health and Care Excellence, 2012).
  13. Content Article
    COVID-19 has created unprecedented pressures for the NHS as a whole including maternity services. How can maternity leaders run a safe and rights respecting maternity service during a pandemic? This guide, produced by Brithrights, sets out a process to support maternity service leaders to reach decisions that help them to achieve this. All those affected by decisions need to be involved in making them. NHS England guidance states that Maternity Voices Partnership Chairs should be involved in decisions about temporary changes to maternity services, in addition to staff and partner organisations.
  14. Content Article
    After babies are born they have to breathe, suck, feed, wee, poo and stay warm. This NHS leaflet (April 2020) will tell you how to keep your baby safe and healthy. Do not delay seeking help if you have any concerns. Content includes: What is jaundice? Breathing, colour and movement. Feeding.
  15. Content Article
    PPROM is the acronym for Preterm Pre-labour Rupture Of Membranes. This is otherwise known as when the waters break prior to 37 weeks during pregnancy. These waters, known as the amniotic fluid, protect the baby from injury. It also helps in preventing infection being passed from mother to baby. As soon as the waters break the risks of infection to both mother and baby are high. Therefore good management of care at this stage is key to treating this condition successfully. Little Heartbeats raise awareness of PPROM, help patients share their experiences and promote the use of the Royal College of Obstetricians and Gynaecology leaflet which contains the guidelines set out for UK hospitals to follow in the event of PPROM.
  16. Content Article
    This Review was announced in the House of Commons on 21 February 2018 by Jeremy Hunt, the then Secretary of State for Health and Social Care. Its purpose is to examine how the healthcare system in England responds to reports about harmful side effects from medicines and medical devices and to consider how to respond to them more quickly and effectively in the future. The Review was asked to investigate what had happened in respect of two medications and one medical device: hormone pregnancy tests (HPTs) – tests, such as Primodos, which were withdrawn from the market in the late 1970s and which are thought to be associated with birth defects and miscarriages; sodium valproate – an effective anti-epileptic drug which causes physical malformations, autism and developmental delay in many children when it is taken by their mothers during pregnancy; and pelvic mesh implants – used in the surgical repair of pelvic organ prolapse and to manage stress urinary incontinence. Its use has been linked to crippling, life- changing, complications; and to make recommendations for the future. The Review was prompted by patient-led campaigns that have run for years and, in the cases of valproate and Primodos over decades, drawing active support from their respective All-Party Parliamentary Groups and the media. 
  17. Content Article
    This is a series of three articles written by Kirsten Small, a specialist obstetrician and gynaecologist in Australia, exploring the risks that flow from the use of intrapartum monitoring. Part 1 Examines evidence of short and long-term physical harms to birthing women relating to higher rates of surgical birth when intrapartum Cardiotocography (CTG) monitoring is used. Part 2 Focuses on possible psychological harms which have been reported relating to CTG use. Part 3 Looks at the possibility that CTG use might cause harm to the baby, while the two previous posts have examined the risk to birthing women.
  18. Content Article
    In this candid blog, 'The Secret Midwife', gives her account of the pressure and lack of resource and support that makes it so difficult to provide safe care.
  19. Content Article
    At seven months pregnant, intensive care doctor Rana Awdish suffered a catastrophic medical event, haemorrhaging nearly all of her blood volume and losing her first child. She spent months fighting for her life in her own hospital, enduring a series of organ failures and multiple major surgeries. Every step of the way, Awdish was faced with something even more unexpected and shocking than her battle to survive: her fellow doctors’ inability to see and acknowledge the pain of loss and human suffering, the result of a self-protective barrier hard-wired in medical training. In Shock is her searing account of her extraordinary journey from doctor to patient, during which she sees for the first time the dysfunction of her profession’s disconnection from patients and the flaws in her own past practice as a doctor. Shatteringly personal yet wholly universal, it is both a brave roadmap for anyone navigating illness and a call to arms for doctors to see each patient not as a diagnosis but as a human being.
  20. Content Article
    Despite increasing recognition of the potential risks associated with in-hospital newborn falls among health professionals, new parents are frequently unaware of the possibility of dropping their newborn, especially in the hospital. Although most newborn falls do not result in lasting harm to the newborn, they may need additional healthcare services and cause stress to the parents.
  21. Content Article
    Football is a popular American pastime. Its focus on collaboration, individual skill reliance and teamwork serves as a touchpoint for the January 2020 Letter from America. Letter from America is a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. 
  22. Content Article
    Babies and young children (under five years) can suffer serious injury if they ingest coin/button batteries or poke them into their nostrils or ears. While the larger lithium batteries have the greatest potential to cause harm, including death, the smaller zinc–air batteries, used in hearing aids, cochlear implants, bone-anchored hearing aids (BAHA) and similar equipment, still present a significant risk. This National Patient Safety Alert requires all organisations supplying NHS-funded hearing aids to ensure those issued to babies and children under five years of age have secure battery compartments. Where hearing aids are issued to older children and adults, organisations are required to consider the need for a secure battery compartment for anyone living with young children and babies, or with a person with additional risk factors, such as those with a significant learning disability, dementia or other cognitive or sensory impairment.
  23. Content Article
    This article, published by Medium, looks at the story of a woman who had a stroke while pregnant. Both survived. The authors highlight a growing concern that the US is in the midst of a maternal morbidity and mortality crisis.
  24. Content Article
    In her blog for the Professional Standards Authority, Sarah Seddon talks about her personal experience as a patient going through the fitness to practise process. She outlines her thoughts on the key considerations that she believes regulators should take into account to help 'humanise' the process.   "I was known as ‘Woman A’. To me, this embodies the entire impersonal, inhumane world of fitness to practise. I wasn’t a person with needs, thoughts and feelings; I wasn’t a bereaved mum; I wasn’t a professional anymore but simply a piece of evidence."
  25. Content Article
    Published in Acta Paediatrica, the parents of a baby who was born prematurely and died, share their experiences of the communication and choices given to them before the birth.
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