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Showing results for tags 'Maternity'.
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Content ArticleThe Health and Care Act 2022 will establish the Healthcare Safety Investigations Branch (HSIB) as the Health Services Safety Investigations Body (HSSIB) in April 2023, a fully independent arm’s-length body. This blog by Dr Sean Weaver, Deputy Medical Director at HSIB, outlines what HSSIB's new powers will be.
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Content Article
AvMA case study: Lyndsey's story
Patient-Safety-Learning posted an article in Risk management and legal issues
This article tells the story of Lyndsey, who was 36 years' old and expecting her third child when she died of shock and haemorrhage, and a perforated gastric ulcer. Sadly, her baby also died as a result of Lyndsey's condition. In her narrative report, the Coroner raised concerns that Lyndsey had been prescribed methadone with no face-to-face consultation, and that she had received a prescription with no planned medical review. She also raised concerns about the reliability of the ambulance pre-alert system due the absence of systems for auditing the effectiveness and reliability of the pre-alert system and the lack of knowledge and training of staff in control. -
Content ArticleThis article in the Manchester Evening News details the experience of Amy, whose daughter Harper was stillborn following failings in Amy's care. After being induced, Amy was left on her own in a room at the Royal Oldham Hospital's maternity unit overnight, without any monitoring. She had raised concerns about her baby's reduced movements but was denied additional checks. When Amy was finally checked in the morning, Harper had no heartbeat. An internal investigation conducted by The Royal Oldham Hospital found that if Amy had received appropriate monitoring, CTG abnormalities would have been noticed. This would have led to an escalation in her care, earlier delivery and Harper is likely to have been born alive.
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Content ArticleEverybody has a right to good care. Much attention is rightly focused on the occasions when people experience poor quality care, but it is also important to recognise where care is good and to celebrate the services that are getting it right. Some care providers do things well through innovative new ways of working, or by doing the basics well. Others can learn from them and solutions should be shared across the system. This publication from the Care Quality Commission (CQC) is purposely focused on celebrating good and outstanding care that CQC's inspectors have seen.
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Content ArticleThis report by Best Beginnings, Home-Start UK and the Parent-Infant Foundation highlights the impact Covid-19 and measures introduced to control its spread have had on babies. It highlights a “baby blindspot” in Covid-19 recovery efforts and a shortage of funding for voluntary sector organisations and core services like health visiting to offer the level of support required to meet families’ needs. The authors of the report spoke to mothers of babies born during the pandemic and surveyed professionals and volunteers who work with babies and their families.
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Content ArticleThis realist evaluation aimed to explore and explain the ways in which a programme initiated by the Scottish Government, Keeping Childbirth Natural and Dynamic (KCND), worked or did not work in different maternity care contexts. KCND was a maternity care programme that aimed to support normal birth by implementing multiprofessional care pathways and making midwife-led care for healthy pregnant women the national norm.
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Content ArticleIdentifying improvements in maternity care to help reduce the risk of delays in crucial interventions during labour when a baby is suspected to be unwell is the focus of this latest Healthcare Safety Investigation Branch (HSIB) report. The report was compiled after a review of 289 of our maternity investigations into intrapartum stillbirths, neonatal deaths and potential severe brain injuries. In 14.9% of the cases the delay was a contributory factor. The review identified issues such as inadequate staffing, poor infrastructure and high workload as contributory factors to the delays. Evidence from national reports confirms that such delays are a recognised patient safety risk.
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Content ArticleObstetric quality of care measures have largely focused on severe maternal morbidity (SMM), with little consensus about measures of less severe but more prevalent delivery and neonatal complications. This study, published in The Joint Commission Journal of Quality and Safety, analyses risk-adjusted maternal and neonatal outcomes using both ICD-10 coding and electronic health record (EHR) data.
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Content ArticleHaving consistent healthcare support during pregnancy, labour and after your baby’s born can make the world of difference. In this webpage, the National Childcare Trust (NCT) focuses on the following questions: What does Continuity of Care in maternity mean? What are the benefits? How can I make continuity of care more likely?
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Content ArticleThis review suggests that women who received midwife-led continuity models of care were less likely to experience intervention and more likely to be satisfied with their care with at least comparable adverse outcomes for women or their infants than women who received other models of care. Further research is needed to explore findings of fewer preterm births and fewer foetal deaths less than 24 weeks, and all foetal loss/neonatal death associated with midwife-led continuity models of care.
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Content ArticleThe purpose of this study, published in Acta Bio-Medica, was to explore the skills of the continuity care of patient operated by the midwife and to research the evidences that support such model. In particular, the aim was to verify whether there are efficacy trials that support the caseload midwifery care model. The questions that have guided this work are the following: Is the midwifery-led care model a safe caring model based on the evidences? Is the continuity of care provided by the midwife during pregnancy and childbirth as safe as the one provided by physicians or multi-professional teams? Is it therefore possible to propose its implementation in the obstetric units in Italy? The second aim was to explore evidence of customer satisfaction with the midwifery-led care model, and to verify also the satisfaction from the midwives who are part of a midwifery-led care model, in terms of job satisfaction and of a good balance between private and professional life.
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Content ArticleThis resource from the Royal College of Midwives, contains practical information and contains interactive exercises for midwives to use on their own or as part of a group, to support implementation conversations relating to continuity of carer.
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Content ArticleThis report, from the Royal College of Midwives, found that continuity of midwifery care contributes to improving quality and safety of maternity care. High quality evidence indicates that women who receive care in these models are more likely to have effective care, a better experience and improved clinical outcomes. There is some evidence of improved access to care by women who find services hard to reach and better co-ordination of care with specialist and obstetric services. Continuity of midwifery care can provide services for all women across all settings, whether women are classified as high or low risk and current evidence shows improved outcomes with no adverse effects in populations of mixed risk. In addition improved birth outcomes also result when women receiving continuity of midwifery care give birth in obstetric units.
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Content ArticleAs set out in Implementing Better Births: Continuity of Carer, continuity of carer means each woman: • Has consistency in the midwife or clinical team that provides hands on care for a woman and her baby throughout the three phases of her maternity journey: pregnancy, labour, and the postnatal period. • Has a named midwife who takes on responsibility for coordinating her care, and for ensuring all her needs and those of her baby are met, at the right time and in the right place, throughout the antenatal, intrapartum and postnatal periods. • Has “a midwife she knows at the birth”. • Is enabled to develop an ongoing relationship of trust with her midwife who cares for her over time.
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Pain is spoken about often within health and social care. Patients might be asked to locate our pain during examinations, to rate our level of pain or to describe the type of pain we are feeling. They may be forewarned of the possibilities of pain occurring during or after procedures or operations. Medical consent forms often include reference to the risk of pain and require a signature to confirm they have been appropriately ‘informed’. Pain can be acute (lasting less than 12 weeks) or chronic (lasting more than 12 weeks), and the way we experience it, our thresholds, can also vary. It can be our body’s way of warning us of potential damage, yet it can also occur when no actual harm is happening to the body.[1] It can cause trauma, physiological reactions, mental health difficulties and chronic fatigue, and can have a huge impact on someone’s quality of life and ability to perform daily tasks.[2] Pain is undoubtedly complex, but is it a patient safety issue?[3] -
Content ArticleDr Bill Kirkup, Chairman of the Morecambe Bay Investigation, presented at the Patient Safety Learning Conference on the common themes that have emerged, and the lessons we need to learn, from the numerous high-profile inquiries in which he has played a leading role.
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Content ArticleSacha Wells-Munro, Maternity Improvement Advisor at NHS Improvement and Professor Tim Draycott, consultant obstetrician and Health Foundation Improvement Science Fellow, present at the Patient Safety Learning Conference the lessons learned from the Morecambe Bay maternity scandal and changes needed to improve the safety of maternity services system wide.
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Content ArticleLearning about healthcare safety often focuses on understanding what has gone wrong, but it is just as important to examine what good looks for safety in maternity units. In this blog, Elisa Liberati describes how she worked with a team and several collaborators to develop a framework describing 7 key features of safety in maternity units. To ensure the study was as rigorous as possible, they combined several different methods and worked in a highly collaborative way across the system. Follow the link below to read the full blog, published by THIS.Institute.
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Content ArticleThe State of Care is the Care Quality Commission (CQC) annual assessment of health care and social care in England. The report looks at the trends, shares examples of good and outstanding care, and highlights where care needs to improve. The care that people received in 2019/20 was mostly of good quality. But while the quality of care was largely maintained compared with the previous year, there was generally no improvement overall. And in the space of a few short months since then, the pandemic has placed the severest of challenges on the whole health and care system in England.
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Content ArticleEnsuring quality of care during pregnancy and childbirth is crucial to improving health outcomes and reducing preventable mortality and morbidity among women and their newborns. In recent years, Perinatal Quality Collaboratives (PQCs) have been driving improvements in perinatal care across the United States. PQCs are state or multistate networks of teams working to improve the quality of care for mothers and babies. PQCs do that by advancing evidence-informed clinical practices and processes using quality improvement principles to address gaps in care. PQCs work with clinical teams, experts and stakeholders, including patients and families, to spread best practices, reduce variation and optimise resources to improve perinatal care and outcomes. The goal of PQCs is to achieve improvements in population-level outcomes in maternal and infant health. In this article, LifeQI outlines the PQC approach, tools LifeQI can offer and some examples of PQCs being run. Life QI is the global web platform where tools, people and data come together to make improvement happen.
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Rethinking Patient Safety: Maternity safety (4 October 2020)
Patient Safety Learning posted an article in Maternity
Suzette Woodward reflects on the recent reports and research into maternal safety and why we need to shift to a Safety II approach. -
Content ArticleThe aim of this study from Jardine et al. was to determine the rate of complicated birth at term in women classified at low risk according to the National Institute for Health and Care Excellence guideline for intrapartum care (no pre-existing medical conditions, important obstetric history, or complications during pregnancy) and to assess if the risk classification can be improved by considering parity and the number of risk factors. The authors found nulliparous women without risk factors have substantially higher rates of complicated birth than multiparous women without a previous caesarean section even if the latter have multiple risk factors. Grouping women first according to parity and previous mode of birth, and then within these groups according to presence of specific risk factors would provide greater and more informed choice to women, better targeting of interventions, and fewer transfers during labour than according to the presence of risk factors alone.
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Content ArticleIn this guest blog for mumsnet, Nadine Montgomery talks about her journey to the Supreme Court to cement patients’ right to make an informed decision. Nadine highlights the lack of information she was given around potential birth risks as a diabetic pregnant women and how, if better informed, she would have made different choices which could have prevented her baby from suffering harm.
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Content ArticleThis is a video recording of a formal meeting (oral evidence session) of the Health and Social Care Select Committee on Tuesday 29 September 2020, as part of their inquiry looking at the Safety of maternity services in England.
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First, Do No Harm — But in a Pandemic, How? (25 September 2020)
Patient Safety Learning posted an article in Blogs
As hospitals in the US braced for the onslaught of coronavirus cases this past spring, they radically restructured and reorganised to help ease the burden on staff and minimise transmission within the hospital. Along with ceasing elective surgeries and transforming floors to allow for care of intubated patients, visitors were forbidden from entering hospitals with few exceptions. Now, several months removed from the peak of the pandemic, a limited number of visitors are allowed at a time. While limiting visitors allows some additional element of physical distancing, how much does a ban actually help our patients, and how much does it hurt them — especially mothers-to-be in the vulnerable perinatal period? Is it possible to limit visitor-spread virus while allowing our patients the dignity and the peace of companionship during one of the most stressful periods of their lives? In this blog, Byrne and Goldfarb look at the consequences of limiting visitors during the pandemic and considers the negative effect this may have on the health of the patient.
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