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Found 500 results
  1. Content Article
    Each Baby Counts is a national quality improvement programme led by the Royal College of Obstetricians and Gynaecologists (RCOG) to reduce the number of babies who die, or are left severely disabled, as a result of incidents occurring during term labour. The Each Baby Counts programme brings together the results of local investigations into stillbirths, neonatal deaths and brain injuries occurring during term labour to understand the bigger picture, share the lessons learned and prevent babies from dying or suffering brain injuries in the future. This report presents key findings and recommendations based on the analysis of data relating to the care given to mothers and babies throughout the UK, to ensure each baby receives the safest possible care during labour. Recommendations Human factors and behaviour: Each Baby Counts has demonstrated that human factors are recurrent themes that need to be urgently addressed at a systemic level. Research is required to establish how to operationalise learning from this report into practice with improved clinical outcomes. Workload and workforce challenges: Develop and fund an appropriate tool to record current workload and anticipate the obstetric care required for the population. This tool should complement the midwifery acuity tools currently implemented nationally. Research is required to identify safe obstetric staffing standards for the workload and acuity, to guide policy-level changes for the workforce. Communication: All staff must be familiar with using their unit emergency communication and escalation protocols, in particular where emergency buzzers are located and how to activate a switchboard emergency call. This should be mandatory in departmental induction and included in simulated escalation calls during local multidisciplinary team training.
  2. Content Article
    Having 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?
  3. Content Article
    This 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.
  4. Content Article
    The 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.
  5. Content Article
    This 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.
  6. Content Article
    This 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.
  7. Content Article
    As 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. The aim of this framework, produced by the Royal College of Midwives, is to help Local Maternity Systems and the Maternity Transformation Programme to measure, consistently, the level of continuity of carer being provided over time, not only to monitor delivery, but also to help evaluate the extent to which particular models realise the benefits set out in evidence. This document summarises the policy expectations and then suggests a measurement framework that draws on existing data, or that can be incorporated into other existing data collection thus imposing minimal burden on health care organisations and staff. It provides clarity in terms of how continuity of carer is to be defined and measured, and benchmark data upon which improvement can be measured.
  8. Content Article
    More information about "Is pain a patient safety issue? (Patient Safety Learning, November 2020)"
    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] In this blog we will focus on several issues where there is a clear overlap between pain and patient safety concerns, inviting further debate and collaboration on this important topic through a series of questions. Consenting to treatment Consenting to treatment is vital to respecting the rights of the patient and ensuring safe care. It is also one area where we see evidence of how patient safety and pain issues can overlap. A recent example of this can be found in the publication of last month’s report of the Independent Medicines and Medical Devices Safety Review, First Do No Harm. This highlighted a number of cases where women were unable to consent to treatment, undergoing pelvic mesh procedures without being aware that mesh would be used.[4][5] Many have since experienced adverse effects of the mesh, including severe and chronic pain, managed now by strong opioid painkillers. While in the above example lack of consent is linked to pain following treatment, there are other cases where patients lack the necessary information regarding pain during a procedure. Women who have undergone outpatient hysteroscopy procedures have highlighted concerns around informed choice, with many given little or no information beforehand about the risk of severe pain. Of those who did experience high levels of pain, some have reported that their doctor continued with the procedure despite their obvious agony, leaving them feeling traumatised and violated. [6-10] These examples go against the legal requirement for patients to be made aware of what a treatment will involve, including the associated risks.[11] They illustrate the relationship that can exist between consent, pain and patient harm. Patient safety points for further discussion: Are there other scenarios we can learn from to understand how consent impacts on pain experience and patient safety? What support do clinicians need to communicate the information in a way that is accessible, comprehensive and patient focussed? Where guidance for clinicians exists[12], why isn’t it being widely used? What can be done to make sure patients feel empowered and supported in halting procedures if the pain becomes unmanageable? Should severe procedural pain be recorded as a Serious Adverse Event? Communication In our report A Blueprint for Action we make clear the importance of engaging patients in patient safety, drawing on evidence that shows that ‘communication between clinicians and patients has a positive impact on health outcomes’.[13] When looking at issues of pain and communication, problems with the latter can often present a barrier to dealing appropriately with a patient’s pain issues. For example, evidence shows that pre-verbal children are far less likely to receive adequate pain control in comparison to their adult or older children counterparts.[14] Their inability to self-report has a direct impact on the level of pain they are likely to have to endure. Poorly managed pain in childhood can cause chronic pain, disability, and distress in adult life.[15] Similarly, there are calls for people with intellectual and developmental disability (IDD) to have their pain better managed, particularly pertinent where self-reporting is not feasible. Researchers have acknowledged the communication barriers faced by patients with IDD and highlight a need for evidence-based, stakeholder-informed methods to be used, in order to assess pain and prevent unnecessary suffering[16]. This raises further questions around disparities in pain relief for patients who may struggle to communicate for other reasons. For example, if being treated in the NHS and where English is not their first language. Patient safety point for further discussion: Can examples be shared where alternative pain assessment tools have been used to meet the needs of patients with communication challenges? Bias and gatekeeping Another overlap between pain and patient safety is when it comes to access to medication and clinicians holding a gatekeeping role in this respect. Here we will look at examples of this in three different health areas: 1) Maternity The pain that women can experience in childbirth is widely recognised. Some report that pain relief was either withheld or not given within a reasonable time when they requested it during labour.[17] There can be different factors that also interact with this, with some women raising concerns around the role that racism or cultural assumptions may play in these circumstances. For example, there is a risk that black women could be denied pain relief because of a common perception that they are stronger and better able to cope.[18-19] Or, that loud vocalisations of pain may be more easily dismissed and wrongly attributed to differences in cultural expression[20], rather than seen as genuine and in need of immediate response. We have also spoken to women who felt that staff were ‘gatekeepers’ to pain relief during their labour, based on their preference leaning towards birthing with no medical intervention. The investigation into patient deaths at Morecambe Bay NHS Foundation Trust maternity and neonatal services found that the presence of such attitudes contributed to unsafe deliveries.[21] The Royal College of Midwives has also faced criticism over the language used in a campaign to encourage expectant mums to give birth without intervention, where vaginal deliveries were referred to as ‘normal births’. The College now uses the term ‘physiological births’. 2) Sickle cell anaemia Bias is evident in several patient groups, particularly in the sickle cell community. Mismanagement of pain in this group is frequent due to the assumptions held by clinicians and healthcare workers.[22] Sickle cell patients may be perceived as hypochondriacs, drug seeking or addicted to pain relief. This often leads to patients waiting long periods without (or with minimal) pain relief and can prevent them from seeking help early, potentially leading to further deterioration.[23] 3) Chronic pain Patients who suffer with chronic pain may also be waiting for long periods without adequate relief, whether attending hospital or seeing a GP. Studies have shown that up to a third of UK adults suffer from chronic pain[24] and, although guidance has been produced,[25-26] there is evidence that clinician assumptions continue. Some, for example, do not accept that Fibromyalgia (a condition that the patient suffers chronic pain) actually exists.[27] Attitudes like this can lead to patients being ignored, dismissed or sent away with minimal intervention. Sadly, for decades patients have been raising concerns around the dismissal, bias and lack of understanding surrounding the management of chronic pain.[28] A recent analysis of tweets from patients, many of whom had chronic pain, showed that harmful doctor-patient communication can impact on diagnostic safety.[29] Patient safety points for further discussion: What training is there for GPs and other clinicians regarding pain management, across different patient groups and demographics? To what extent do assumptions and biases impact how patients experience pain more broadly throughout health and social care? To what extent does institutional racism play a part? Differences in pain experience Research suggests that pain thresholds can vary. Low pain tolerance has been attributed to patients with fibromyalgia, chronic fatigue syndrome[30] and intellectual and developmental disabilities[31]. Studies have also shown that gender[32], ethnicity[33] and previous trauma[34] can all contribute to people experiencing pain differently. With research indicating there are notable differences in pain thresholds, it leads us to question whether all patients have equal access to the pain relief needed to reasonably ease suffering. Patient safety points for further discussion: Are some patients at greater risk of experiencing trauma-inducing levels of pain than others? Do the methods used for determining how much pain relief to give an individual adequately recognise differences in thresholds, across all demographics? We’d like to hear your views In some ways, we end as we began - with an understanding that pain is incredibly complex. The growing concerns around opioid reliance and over-prescription add another dimension to the conversation and will challenge our thinking further. Eliminating pain altogether would undoubtedly have implications for how we are able to listen to our bodies and adjust accordingly to recover or prevent damage. However, there is clearly much to learn in order to manage peoples’ pain needs safely, effectively and without perpetuating inequalities. And we cannot ignore the continued presence of both acute and chronic pain in incidences of patient harm. Patients are describing their personal, and sometimes deeply traumatic, experiences to help key decision-makers identify where change may be needed and prevent future suffering. Their insight and lived-experience will prove crucial to this debate. The limited examples used in this blog are designed to trigger wider conversations about how we may work together to understand pain as a broader patient safety issue. We welcome the input of others who have an interest in this area. Please comment below or get in touch with the Patient Safety Learning team by emailing [email protected]. References [1] British Pain Society, Useful definitions and glossary. [2] Katz N, The Impact of Pain Management on Quality of Life. Journal of Pain and Symptom Management 2002; 24; 38-47. [3] Twycross A, Forgeron P, Chorne J et al. Pain as the neglected patient safety concern: Five years on. Journal of Child Health Care. 2016; 20 (4): 537-541. [4] The Independent Medicines and Medical Devices Safety Review. First Do No Harm 2020. [5] Patient Safety Learning. Findings of the Cumberlege Review: informed consent. Patient Safety Learning’s the hub 2020. [6] Patient Safety Learning. Painful Hysteroscopy. Patient Safety Learning’s the hub, Community Forum. 2020. [7] Women’s Hour. Hysteroscopy. 2019. [8] Discombe M. Hundreds of women left ‘distressed’ by hysteroscopies. Health Service Journal 2019. [9] Care Opinion. Painful hysteroscopy and biopsy. 2019. [10] Hysteroscopy Action campaign website. [11] The Supreme Court. Montgomery v Lanarkshire Health Board. 2015. [12] Royal College of Obstetricians and Gynaecologists, Outpatient Hysteroscopy. 2018. [13] Patient Safety Learning. The Patient-Safe Future: A Blueprint For Action. 2019. [14] Kirkey S. Study suggests more can be done to control pain for children. Ottawa Citizen 2014. [15] Eccleston C, Fisher E, Howard R et al. Delivering transformative action in paediatric pain: a Lancet Child & Adolescent Health Commission 2020. [16] Barney, Chantel C, Andersen et al. Challenges in pain assessment and management among individuals with intellectual and developmental disabilities. PAIN Reports 2020; 4; 821. [17] Hill A. Women in labour being refused epidurals, official inquiry finds. The Guardian 2020. [18] Patient Safety Learning. Racial disparities in postnatal mental health: An interview with Sandra Igwe the Founder of The Motherhood Group. Patient Safety Learning’s the hub 2020. [19][19] Patient Safety Learning. Five X More campaign: Improving maternal mortality rates and health outcomes for black women. Patient Safety Learning’s the hub 2020. [20] Wyatt R. Pain and Ethnicity. Virtual Mentor. 2013; 15(5); 449-454. [21] Kirkup B. The Report of the Morcambe Bay Investigation. 2015. [22] Smith-Wynter L, van den Akker O. Patient perceptions of crisis pain management in sickle cell disease: a cross-cultural study. NT Research. 2000;5(3):204-213. [23] Hall S. “People with Sickle Cell are seen as hypochondriacs or drug addicts. Even a nine-year-old has to scream to get the care they need”. Picker. [24] NICE. Chronic pain: assessment and management. Guideline scope. 2018. [25] NICE. Analgesia - mild-to-moderate pain. Accessed 2020. [26] NICE. Chronic pain: assessment and management (in development). Page accessed 2020. [27] Häuser W, Fitzcharles MA. Facts and myths pertaining to fibromyalgia. Dialogues Clin Neurosci. 2018; 20 (1): 53-62. [28] Rehmeyer J. Bad science misled millions with chronic fatigue syndrome. Here’s how we fought back. Stat News. 2016. [29] Sharma AE, Mann Z, Cherian R et al. Recommendations From the Twitter Hashtag #DoctorsAreDickheads: Qualitative Analysis. J Med Internet Res 2020; 22 (10): e17595 [30] Dellwo A. Pain Threshold and Tolerance in Fibromyalgia and CFS. Verywell Health. 2020. [31] Barney, Chantel C, Andersen et al. Challenges in pain assessment and management among individuals with intellectual and developmental disabilities. PAIN Reports: 2020; 5 (4); 821 [32] Mogil J, Bailey A. Chapter 9 - Sex and gender differences in pain and analgesia. Progress in Brain Research 2010; 186;-157. [33] Wyatt R. Pain and Ethnicity. Virtual Mentor. 2013; 15(5); 449-454. [34] Mostoufi S, Godfrey KM, Ahumada SM, et al. Pain sensitivity in posttraumatic stress disorder and other anxiety disorders: a preliminary case control study. Ann Gen Psychiatry 2014; 13 (1): 31.
  9. Content Article
    Dr 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.
  10. Content Article
    Sacha 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.
  11. Content Article
    Learning 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.
  12. Content Article
    This report presents the findings from the Care Quality Commission’s (CQC) recent national maternity inspection programme. It highlights common issues impacting on the quality and safety of NHS hospital maternity services across the country. Of the 131 locations we inspected between August 2022 and December 2023, almost half were rated as requires improvement (36%) or inadequate (12%). The quality and safety of maternity services have remained under scrutiny in recent years. While a series of high-profile investigations identified key failings at specific NHS trusts, CQC's National maternity inspection programme – an inspection of all hospital maternity locations that had not been inspected since before March 2021 – has shown many of the issues raised are widespread across England. Although CQC identified pockets of excellent practice, they are concerned that too many women and babies are not receiving the high-quality maternity care they deserve. Of the 131 locations we inspected between August 2022 and December 2023, almost half were rated as requires improvement (36%) or inadequate (12%). Only 4% of services were rated as outstanding and 48% were rated as good. At 12 locations, ratings for being well-led dropped by 2 ratings levels and at 11 locations, ratings for being safe dropped by 2 levels. The safety of maternity services remains a key concern, with no services inspected rated as outstanding for being safe. Almost half (47%) were rated as requires improvement for the safe key question, while 35% were rated as good and 18% were rated as inadequate. Recommendations For NHS trusts and integrated care boards (ICBs) Improve their collection of demographic data, including information on ethnicity and levels of deprivation, to improve outcomes for women. Ensure that demographic data, including ethnicity data, is always considered when reviewing patient safety incidents and action is taken where risks are identified. Ensure that there are clear policies and procedures on the collection of demographic information and staff understand the importance of how this data can be used to improve outcomes for women. For NHS England Develops guidance and definitions of a patient safety event, where something unexpected or unintended happens in maternity services, ensuring reporting in line with Learn from Patient Safety Events (LFPSE), to tackle the issue of inconsistency in interpretation. Oversees the performance of maternity triage services to enable trusts to benchmark and improve. This is in line with the Royal College of Obstetricians and Gynaecologists (RCOG) recommendation to introduce “an agreed national standard and reporting tool for maternity triage, similar to that used in emergency medicine.” As outlined by RCOG, metrics should include “staffing requirements, agreed audit standards reported nationally, and frameworks for improvement.” Has oversight of gaps in middle-grade rotas and the proportion of time spent by consultants covering them. This supports recommendations in the Ockenden Review to introduce nationally agreed minimum levels of medical staff to cover the full range of maternity services at all times. Works with the Nursing and Midwifery Council and Royal College of Obstetricians and Gynaecologists to establish a minimum national standard for midwives delivering high dependency maternity care. Ensures trusts are proactively managing succession planning in midwifery services and, In line with recommendations from Leadership for a collaborative and inclusive future review, supports midwifery and obstetric staff to become effective future leaders. For the Department of Health and Social Care (DHSC) Provides additional capital investment in maternity services to ensure that women receive safe, timely care in an environment that protects their dignity and promotes recovery. Works with NHS England to ensure that this additional investment is ring-fenced and maternity services receive the investment they need. For the Royal College of Obstetricians and Gynaecologists The Royal College of Obstetricians and Gynaecologists takes the findings in relation to the surgical first assistant role in maternity services so that it is in line with the requirements set out by the Royal College of Surgeons. For the Nursing and Midwifery Council The Nursing and Midwifery Council uses findings from the report to review their proficiency standards for midwives.
  13. Content Article
    More information about "Using barcode scanning technology to improve blood group testing in unborn babies"
    In this blog for World Patient Safety Day, the NHS Blood and Transfusion (NHSBT) and the Scan4Safety Team in the NHS England National Patient Safety Team explore how barcode scanning technology has improved testing for the D blood group in unborn babies. This technology has made the process more efficient, reduced errors and improved patient experience. This blog has been published as part of a series for World Patient Safety Day 2024 and the theme of Improving diagnosis for patient safety. #WPSD24, World Patient Safety Day 2024, WPSD 2024. The importance of D blood group testing The D blood group tests help prevent haemolytic disease of the foetus and newborn (HDFN), a serious condition that can cause anaemia, jaundice, brain damage or, in extreme cases, death. HDFN occurs when a mother’s blood group is incompatible with her baby’s. If a D-negative mother is carrying a D-positive baby, the mother’s immune system may produce antibodies that attack the baby’s red blood cells, leading to life-threatening conditions. To prevent this, anti-D immunoglobulin (anti-D Ig) is given to D negative mothers during pregnancy. However, this treatment is only necessary if the baby is D-positive. The only way to determine the unborn baby’s D blood group is through testing. How D blood group testing works The baby’s blood group is determined by analysing its DNA, a small amount of which is present in the mother’s blood. A blood sample is taken from the mother and sent to NHSBT’s Molecular Diagnostics Laboratory in Bristol for testing. Results had previously been available within 10 working days to help clinicians decide if anti-D Ig is needed. The role of barcode scanning in enhancing accuracy Traditionally, the requesting process relied on manual, paper-based systems, which were prone to errors. Mistakes in filling out forms or entering data could lead to delays, incorrect results, and even the need for re-tests, causing stress to expectant mothers. Recognising the limitations of manual systems, NHSBT has piloted the introduction of barcode scanning technology. This has significantly improved accuracy, efficiency and patient safety through the following: Accurate sample identification: Each blood sample is assigned a unique barcode linked to the mother’s medical record. This ensures the sample is accurately identified throughout the testing process. From the moment the sample is collected to when it is processed in the lab, the barcode is scanned at every stage, reducing the risk of misidentification or human error. Seamless data transfer: Barcodes allow accurate transfer from the hospital to the lab. When the sample arrives at the Bristol lab, staff simply scan the barcode and all the necessary information is automatically pulled from the hospital’s system. This eliminates manual data entry and prevents transcription errors, ensuring that testing can process without unnecessary delays. Faster workflow: Integrating barcode scanning with electronic systems has streamlined the entire process. Laboratory staff no longer need to fill out paper forms or manually enter data, saving time and allowing quicker processing. Results are returned faster, reducing turnaround times from 10 days to as little as 3 days. Improved patient experience: Rejected samples and delays due to errors in the manual process can cause stress and anxiety for patients. Barcode scanning reduces the number of re-tests, meaning fewer mothers need to provide another blood sample. This improves the overall patient experience by ensuring timely and accurate care. A patient-centred approach Anna Mamwell, patient and public involvement lead for the Transfusion 2024 programme, highlighted the importance to patients of using this technology: “It's important that the concerns of patients are acknowledged and addressed, with quality and safety high on that list. As a patient representative, I welcome and encourage the E requesting and reporting system. This will not only improve the patient experience but contribute to providing a safe, efficient and trustworthy service which is essential to the health and wellbeing of patients and their unborn baby.” The future of barcode scanning in healthcare NHSBT is working to expand electronic requesting and reporting to all hospitals across England, aiming to use it for all pathology tests. This shift is a crucial step towards improving healthcare delivery, patient safety, and maternal care. Scan4Safety’s role Scan4Safety is focused on the implementation of end-to-end barcode scanning technology across the NHS. This technology enhances patient safety through accurate point-of-care scanning and reducing errors in data entry and documentation. The use of barcode scanning in foetal D blood group testing by NHSBT showcases how innovative technology can transform patient care. This use of barcode scanning is making a significant positive impact in maternity services by minimising errors, speeding up test results and improving operational efficiency. The photo at the top of the page is Helen Thom, RCI Development Lead – Transfusion 2024, Clinical Services, NHS Blood & Transplant. This blog has been published as part of a series for World Patient Safety Day 2024 and the theme of Improving diagnosis for patient safety. #WPSD24, World Patient Safety Day 2024, WPSD 2024.
  14. Content Article
    There is a policy drive in NHS maternity services to improve open disclosure with harmed families and limited information on how better practice can be achieved.The objectives of this study, published in Health and Social Care Delivery Research, were to identify critical factors for improving open disclosure from the perspectives of families, doctors, midwives and services and to produce actionable evidence for service improvement.Authors concluded:"We identify the need for service-wide systems to ensure that injured families are positioned at the centre of post-incident events, ensure appropriate training and post-incident care of clinicians, and foster ongoing engagement with families beyond the individual efforts made by some clinicians for some families. The need for legislative revisions to promote openness with families across NHS organisations, and wider changes in organisational family engagement practices, is indicated. Examination of how far the study’s findings apply to different English maternity services, and a wider rethinking of how family diversity can be encouraged in maternity services research."
  15. Content Article
    This multinational study of 4,511,267 pregnancies in JAMA Neurology aimed to assess the associations between maternal epilepsy, antiseizure medication use during pregnancy and risks of severe maternal and perinatal morbidity and mortality. It found that: women with epilepsy were at considerably higher risk of severe maternal and perinatal outcomes and increased risk of death during pregnancy and postpartum. maternal epilepsy and maternal use of antiseizure medication were associated with increased maternal morbidity and perinatal mortality and morbidity. The authors identified an urgent need for enhanced counselling, perinatal support and access to specialised care for safe deliveries in all women with epilepsy.
  16. Content Article
    More information about "New FREE eLearning module on group B Strep (30 July 2024)"
    The charity Group B Strep Support have launched a new FREE eLearning module on group B Strep and it comes with one hour of Continued Professional Development (CPD) credit.  This vital resource is for midwives, doctors and others working in maternity and neonatal care. It has been co-produced with families, midwives, obstetricians, neonatologists and others involved in maternity and neonatal services.   The module takes around 30-40 minutes to complete and provides an overview of group B Strep. It’s based on the latest guidelines from the Royal College of Obstetricians & Gynaecologists and the National Institute for Health and Care Excellence.  
  17. Content Article
    NHS Resolution have published an animation designed to explain what their Early Notification Scheme does. It aims to be clear, concise and understandable for any families who might have experienced an incident of maternity harm and have been accepted onto the EN Scheme or are seeking to understand more about what the scheme does. It also acts as an important signpost for further support for families and where they can contact our internal teams for more information if needed. 
  18. Content Article
    This is the tenth MBRRACE-UK Perinatal Mortality Surveillance Report. The report is divided into five sections: perinatal mortality rates in the UK; mortality rates for Trusts and Health Boards; mortality rates by gestational age; mortality rates by ethnicity and socio-economic deprivation; and a description of the causes of perinatal death. This report focuses on births from 24 completed weeks’ gestational age, with the exception of the section on mortality rates by gestational age, which also includes information on births at 22 to 23 completed weeks’ gestational age. This avoids the influence of the wide disparity in the classification of babies born before 24 completed weeks’ gestational age as a neonatal death or a late fetal loss. Terminations of pregnancy have been excluded from the mortality rates reported. Additional supporting materials to accompany this report include: a set of reference tables a data viewer with interactive mapping, which presents mortality rates for individual organisations, including Trusts and Health Boards a technical manual containing full details of the MBRRACE-UK methodology, including definitions, case ascertainment and statistical methods.
  19. Content Article
    This film demonstrates how using SEIPS can help illuminate contributory factors within a work system, such as unconscious bias, stereotyping, workload, incivility, societal pressures and environmental factors under the six entity headings. Staff watch an animated explanation of SEIPS and then a short fictional maternity scenario looking out for relevant contributory factors. After viewing the film staff take part in a facilitated discussion to reflect. It is hoped that those using this film will be able to build on this experience, and then reflect on their own clinical service through the SEIPS lens, as taking a systems-based approach will strengthen a Just Culture, reduce blame and supports the PSIRF process.
  20. Content Article
    More information about "Top picks: 6 resources about Group B Strep"
    Knowing about Group B Strep when you’re pregnant or in the early weeks after birth can make a massive difference – most Group B Strep infections in newborn babies can be prevented, and early treatment can and does save lives. Group B Strep Awareness Month focuses on empowering new and expectant parents with the knowledge they need to make informed decisions about their baby and engaging with healthcare professionals to improve education and awareness.  In this blog, Patient Safety Learning has pulled together six useful resources about Group Strep B shared on the hub. 1 Leaflet on Group B Strep The charity Group B Strep Support (GBSS) has produced an information leaflet, written in partnership with the Royal College of Obstetricians and Gynaecologists (RCOG), aimed particularly at pregnant people and new parents and includes information on what Group B Strep is, what it could mean for a baby, how to reduce the risk and the key signs of Group B Strep infection. The leaflet has been translated from English into 14 other languages 2 Group B Strep: Poppy's story Group B Strep is a type of bacteria which lives in the intestines, rectum and vagina of around 2-4 in every 10 women in the UK (20-40%). Most women carrying GBS will have no symptoms and although it is not harmful to pregnant women, it can affect babies around the time of birth. Read Poppy's story. 3 Leading for safety: A conversation with Jane Plumb, Founder of Group B Strep Support Jane Plumb is the Co-Founder of Group B Strep Support and the Women's Voices Lead for the Royal College of Obstetricians & Gynaecologists. In this interview, she emphasises the importance of actively involving patients and families in patient safety discussions so that improvements can be informed by their insights and experiences. 4 New FREE eLearning module on group B Strep (30 July 2024) The charity Group B Strep Support have launched a new FREE eLearning module on group B Strep and it comes with one hour of Continued Professional Development (CPD) credit. This vital resource is for midwives, doctors and others working in maternity and neonatal care. It has been co-produced with families, midwives, obstetricians, neonatologists and others involved in maternity and neonatal services. 5 HSIB National Learning Report: Severe brain injury, early neonatal death and intrapartum stillbirth associated with group B streptococcus infection This report published in 2020 highlighted a number of patient safety concerns and recommends that maternity care providers should consider the findings and make necessary changes to their local systems to ensure that mothers and babies receive care in line with national guidance. 6 Symptoms of group B Strep infection in babies In the UK, up to two-thirds of GBS infection in babies are of early onset (showing within the first 6 days of life). Group B Strep Support have produced an awareness poster highlighting the symptoms.
  21. Content Article
    The Joint British Diabetes Societies (JBDS) for Inpatient Care group was created in 2008. It aims to improve inpatient diabetes care by developing and promoting high quality evidence-based guidelines and creating better inpatient care pathways. The JBDS–IP group was created and supported by Diabetes UK, ABCD and the Diabetes Inpatient Specialist Nurse (DISN) UK group, and works with NHS England, TREND-UK and with other professional organisations. This webpage contains guidance on a wide range of subjects relating to inpatient care for people with diabetes, including: The hospital management of hypoglycaemia in adults with diabetes mellitus The management of diabetic ketoacidosis in adults Management of adults with diabetes undergoing surgery and elective procedures: improving standards Self-Management of diabetes in hospital Glycaemic management during enteral feeding for people with diabetes in hospital The management of the hyperosmolar hyperglycaemic state (HHS) in adults with diabetes Admissions avoidance and diabetes: guidance for clinical commissioning groups and clinical teams Management of hyperglycaemia and steroid (glucocorticoid) therapy The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients Discharge planning for adult inpatients with diabetes Management of adults with diabetes on dialysis Managing diabetes and hyperglycaemia during labour and birth with diabetes The management of diabetes in adults and children with psychiatric disorders in inpatient settings A good inpatient diabetes service Inpatient care of the frail older adult with diabetes Diabetes at the front door The management of glycaemic control in people with cancer COncise adVice on Inpatient Diabetes (COVID:Diabetes) - hyperglycaemia Optimal staffing for a good inpatient diabetes service Using technology to support diabetes care in hospital
  22. Content Article
    A fire at the University Hospital of Leicester in 2023 led to the recommendation of a full evacuation of the tertiary neonatal unit. The incident was ultimately stood down—however, it highlighted the lack of inter-agency understanding regarding the difficulty and complexity of moving critically unwell and premature babies in the event of a major incident. In response, the Leicester Royal Infirmary and other agencies staged a simulation exercise to enable teams to prepare for possible future incidents. This HSJ article describes the simulation exercise and the lessons it revealed about managing neonatal unit evacuations during major incidents. It highlights key learnings around the two themes of communication and estates.
  23. Content Article
    How are community groups bridging some of the gaps between Black mothers and health and care services? What can the health and care system learn in response? Siva Anandaciva speaks to Amanda Smith, founder and Chief Executive of Maternity Engagement Action CIC, Benash Nazmeen, Professor of Midwifery and co-founder and co-director of the Association of South Asian Midwives CIC, and Chrissy Brown, founder and Chief Executive of the Motivational Mums Club CIC, to find out.
  24. Content Article
    Suicide is a leading cause of maternal death during the perinatal period, which includes pregnancy and the year after birth. While maternal suicide is a relatively rare event with a prevalence of 3.84 per 100,000 live births in the UK, the impact of maternal suicide is profound and long-lasting. Many more women will attempt suicide during the perinatal period, with a worldwide estimated prevalence of 680 per 100,000 in pregnancy and 210 per 100,000 in the year after birth. This qualitative study aimed to explore the experiences of women and birthing people who had a perinatal suicide attempt and to understand the context and contributing factors surrounding their perinatal suicide attempt. The researchers spoke to women with lived experience of perinatal mental illness. Their results highlighted three key themes: Trauma and Adversities which captures the traumatic events and life adversities with which participants started their pregnancy journeys. Disillusionment with Motherhood which brings together a range of sub-themes highlighting various challenges related to pregnancy, birth and motherhood resulting in a decline in women’s mental health. Entrapment and Despair which presents a range of factors that lead to a significant deterioration of women’s mental health, marked by feelings of failure, hopelessness and losing control. The authors called for further research into these factors which could lead to earlier detection of suicide risk, improving care and potentially prevent future maternal suicides.
  25. Content Article
    Implementing levels of maternal care is one strategy proposed to reduce maternal morbidity and mortality. The levels of maternal care framework outline individual medical and obstetrical comorbidities, along with hospital resources required for individuals with these different comorbidities to deliver safely. The overall goal is to match individuals to hospitals so that all birthing people get appropriate resources and personnel during delivery to reduce maternal morbidity. This study examined the association between delivery in a hospital with an inappropriate level of maternal care and the risk of experiencing severe maternal morbidity.

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