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Content Article
RCOG/RCM: Undermining toolkit
PatientSafetyLearning Team posted an article in Maternity
The undermining toolkit is an RCOG/Royal College of Midwives (RCM) initiative to address the challenge of undermining and bullying behaviour in maternity and gynaecology services. The toolkit is divided into four sections that can be used independently: Strategic interventions - Recommendations for over-arching institutions such as the wider NHS, GMC, RCOG, RCM and others Unit, trust and local education provider interventions- Recommendations for trusts and hospitals Departmental and team interventions - Recommendations for departments, particularly around team working between obstetricians and midwives Individual interventions - Recommendations for individual victims and perpetrators of undermining. Follow the link below for more information. -
Content ArticleA new study from Praharaj and Stanciu provides guidance for clinicians discussing the risks of ADHD medications with their pregnant patients.
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Content ArticleThe purpose of this guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) is to urge all maternity units to consider the use of the Maternity Dashboard to plan and improve their maternity services. It serves as a clinical performance and governance score card to monitor the implementation of the principles of clinical governance on the ground. This may help to identify patient safety issues in advance so that timely and appropriate action can be instituted to ensure a woman-centred, high-quality, safe maternity care.
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Content Article
The RCM standards for midwifery services in the UK
Patient Safety Learning posted an article in Maternity
Crucial reports and strategic reviews about the quality of maternity care in different parts of the UK have consistently identified that improvements should be underpinned by implementation of existing evidence-based clinical standards. The Royal College of Midwives (RCM) identified that to deliver compassionate, well-led, professional evidence-based midwifery care which maximises midwives’ contributions to improving quality also required midwifery service standards within a framework which could be used by service providers, commissioners and RCM members. A small project team was tasked with developing The RCM Standards for midwifery services in the UK. The team developed the standards using a pragmatic review of the evidence available and through consensus informed by views, comments and suggestions on draft outputs from respondents. -
Content ArticleBetter Births set out a compelling view of what maternity services should look like in the future. The vision is clear: we should work together across organisational boundaries in larger place-based systems to provide a service that is kind, professional and safe, offering women informed choice and a better experience by personalising their care. Whilst Better Births described the vision, this resource pack sets out in detail what needs to be done and how it can be accomplished across the whole of England. It is designed to provide tools to help Local Maternity Systems turn the vision into reality and the practical advice needed to plan, commission and operate maternity services in their localities.
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Content ArticleThis was a debate in the House of Lords on the 2 March 2021 concerning the UK Government's plans regarding a redress scheme for those harmed by sodium valproate, stemming from recommendations in the First Do No Harm Report by the Independent Medicines and Medical Devices Safety Review chaired by Baroness Cumberlege (also known as the Cumberlege Review).
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Content ArticleFor World Patient Safety Day, Natasha Swinscoe, Patient safety national lead for the AHSN Network and CEO, West of England AHSN, highlights the difference the AHSNs and Patient Safety Collaboratives have made in safe maternal and newborn care.
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The Patients Association: World Patient Safety Day 2021
Patient Safety Learning posted an article in Maternity
While childbirth in the UK is generally a safe event, progress to improve safety seems to have stalled, and how safe mums and babies are depends on where you are and who you are, writes the Patients Association in this article for World Patient Safety Day. The Patients Association firmly believe that involving patients in their care improves outcomes and safety. Mums-to-be developing plans with the midwives and obstetricians seems a perfect example of this. However, research shows that clinicians meaningfully partnering with patients is not mainstream practice. "It will take leadership, training and funding to make patient partnership in maternity care everyday practice", says the Patient Association. "This World Patient Safety Day we call on all those in a position to bring about change in how maternity care is delivered and to pledge to introduce true patient partnership." -
Content Article
World Patient Safety Day 2021
Patient Safety Learning posted an article in Maternity
In this blog Patient Safety Learning marks World Patient Safety Day 2021. It sets out the scale of avoidable harm in healthcare, what needs to change to create a patient safe future and considers the theme of this year’s World Patient Safety Day, ‘Safe maternal and newborn care’. -
Content ArticleThe number of intrapartum stillbirths referred to the Healthcare Safety Investigation Branch (HSIB) between April and the end of June 2020 increased compared to the same time in the previous year. The data initiated a HSIB national learning report, which explores the findings from their maternity investigations during this time. They investigated intrapartum (labour) stillbirths after 37 weeks, where a baby was thought to be alive at the start of labour and was born with no signs of life.
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Content ArticleThe 17 September marks World Patient Safety Day, and this year the focus is on ‘Safe maternal and newborn care’. Recently there has been greater research attention on patient safety in low- and middle-income countries due to the global awareness of the need to improve safety standards for all patients, including in maternal care. In this blog, I highlight the scale of maternal and newborn death in low- and middle-income countries, the contributing factors to this, and the need to improve maternal health and safety.
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At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That’s why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples. This month, to mark World Patient Safety Day 2021 on the 17 September, we’ve selected seven resources related to this year’s theme, ‘Safe maternal and newborn care’. Shared with us by hub members, charities and patient safety advocates, they provide valuable insights and practical guidance on a broad range of maternity safety topics. -
Content ArticleThe Royal College of Obstetricians and Gynaecologists reviewed maternity care at two hospitals: The Royal Glamorgan hospital Prince Charles hospital The report makes recommendation on improvements to ensure the safety of mothers and babies. "During interviews and in group sessions the assessors were repeatedly and consistently told by staff of a reluctance to report patient safety issues because of a fear of blame, suspension or disciplinary action." "The assessors found little evidence among staff at all levels and professional backgrounds, of a coherent approach towards patient safety, or an understanding of their roles and responsibilities towards patient safety beyond the care they provided for a specific woman or group of women. This perception extended to senior members of midwifery and medical staff."
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This joint letter calls on Nadine Dorries MP, Minister for Patient Safety, Suicide Prevention and Mental Health, to urgently fund a confidential enquiry into the deaths of Asian and Asian British babies. It is signed by the Chief Executives of Sands, The Royal College of Midwives, NCT and the President of the Royal College of Obstetricians and Gynaecologists. -
Content ArticleDerek Richford talks to Rob Behrens about the loss of his newborn grandson, Harry, at East Kent Hospitals University Trust. He explains how his sheer persistence uncovered the truth of what went wrong and eventually led to a criminal investigation at the Trust. He also tells us what organisations involved in the complaint process can learn from his family's tragic experience.
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Content ArticleThere are estimated 24 000–60 000 women who are pregnant and incarcerated worldwide and they often lack access to antenatal care at the same level as that available in their communities. Despite clear international standards that mandate equivalent care for people in prison, pregnant women in these settings face significant barriers to adequate antenatal care. The needs of pregnant women are often overlooked in prisons designed to house men . We must not forget this vulnerable and hidden cohort of women. Molly Skerker et al. explore the challenges for pregnant women in prisons worldwide.
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Content ArticleThe Royal College of Midwives (RCM) has warned that measures to reduce pressure on maternity services are putting safety at risk. In a letter to Jacqueline Dunkley-Bent, Chief Midwifery Officer at NHS England, the RCM acknowledges the effectiveness of some measures to relieve pressure on staff and services, but expresses concern at others.
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In this blog Patient Safety Learning looks ahead to World Patient Safety Day 2021 and considers its theme, ‘Safe maternal and newborn care’. -
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HSIB maternity programme year in review 2020/21 (August 2021)
Mark Hughes posted an article in HSSIB investigations
This report provides a review of the Healthcare Safety Investigation Branch (HSIB) maternity investigation programme during 2020/21, including an overview of activity during this period, themes arising from investigations and plans for the future. It is intended for healthcare organisations, policymakers and the public to understand the work HSIB have undertaken. -
Content ArticleThe Royal College of Midwives is calling for "common sense" from NHS trusts and boards on staff access to water and other drinks. The college is concerned that the health and wellbeing of midwives could be in jeopardy as a result of having limited opportunities to stay hydrated on long, hot shifts. .In new guidance to its members, the RCM sets out the importance of staying hydrated on shift and the potential implications of not doing so. These included an impact on decision making, memory, attention span, mood and tiredness. The document also debunks myths suggesting that having fluid bottles on units is a cross infection risk.
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This discussion paper, published in The Journal of Patient Safety and Risk Management, explores some of the opportunities which healthcare organisations could embrace to positively influence the effects of power and hierarchy on staff safety. The author concludes: "This exploration into how power and hierarchy influence both staff and patient safety has identified and briefly explored some of the tensions created by misplaced brand loyalty inherent within healthcare institutions, and the legacy of harms resulting." -
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Pregnant people receive many public health messages that are intended to guide their decision making; intended to improve outcomes for babies and mothers. However, there is growing concern that messages do not always fully reflect or explain the evidence base underpinning them, and that negotiating the risk landscape can sometimes feel confusing, overwhelming, and disempowering. This may negatively affect women’s experiences of pregnancy and motherhood, and be exacerbated by a wider culture of parenting that tends to blame mothers for all less-than-ideal outcomes in their children. The WRISK Project draws on women’s experiences to understand and improve the development and communication of risk messages in pregnancy. -
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House of Commons Debate - Reducing Baby Loss (20 July 2021)
Mark Hughes posted an article in Maternity
This is the transcript of a backbench debate in the House of Commons focused on the UK Government's National Maternity Ambition to halve the rate of stillbirths, neonatal and maternal deaths and brain injuries that occur during or soon after birth by 2025, and to achieve a 20% reduction in these rates by 2020. -
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Written evidence submitted by Donna Ockenden (EPE0025)
PatientSafetyLearning Team posted an article in Maternity
In this written evidence, submitted to the Health and Social Care Select Committee, the Independent Maternity Review Team provides commentary on the following commitment: "The majority of women will benefit from the ‘continuity of carer’ model by 2021, starting with 20% of women by 2019." They outline a number of concerns around the safe implementation of Continuity of Carer, particularly where there are significant staff shortages and/or inadequate funding. -
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This week the Department of Health and Social Care released the UK Government’s response to the recommendations of the Independent Medicines and Medical Devices Safety Review, sometimes referred to as the Cumberlege Review. In this blog Patient Safety Learning sets out its reflections on this.
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