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Found 404 results
  1. Content Article
    This blog in The BMJ Opinion by Steph O'Donohue, content and engagement manager at Patient Safety Learning, looks at the benefits and potential risks of the midwifery continuity of carer model. Steph highlights that seeing the same midwife throughout pregnancy and during labour allows patient and midwife to build a relationship of trust and results in improved outcomes for patients and their babies. She argues that patients and families would be more vocal advocates for continuity of carer if they better understood the benefits of the model. Further reading: Midwifery Continuity of Carer: What does good look like?' Midwifery Continuity of Carer: Frontline insights The benefits of Continuity of Carer: a midwife’s personal reflection
  2. News Article
    A TikTok user who went viral with a video of herself removing her implanted birth control device has prompted calls among sexual health experts for better monitoring of social media platforms. In a video which has gained over 178,000 likes, TikTok user Mikkie Gallagher is filmed performing a ‘DIY IUD removal’ wearing medical gloves, writing on top of the post: “A lot easier than I thought TBH,” and “Catch of the day: Mirena IUD, 2 inches”. An intrauterine device (IUD) is inserted into the uterus to prevent pregnancy and sometimes assist in relieving period pain. They usually need to be taken out every five to 10 years depending on the type. Women can choose when to have them removed. Family Planning Victoria CEO, Claire Vissenga, said she found it very concerning that “DIY could pass as healthcare or professional assistance”. “... it’s just a ridiculous thing to do. Removing an IUD potentially does physical damage, and could complicate contraception,” says Vissenga Family Planning medical director, Kathleen McNamee, said 80% of DIY IUD removals failed, leading to GP or emergency visits. “If the person dislodges the IUD in a failed attempt, it could no longer be effective as a contraceptive method and result in an unwanted pregnancy,” she said. Read full story Source: The Guardian, 24 September 2021
  3. News Article
    A woman with stage 4 endometriosis said she was told she needed to "be more positive" before her diagnosis - despite heavy blood loss and pain. Anna Cooper, from Newbridge, Wrexham, started her periods at 11 and by the time she turned 14, her mother was pushing for a referral. Since then she has had 13 surgeries, with a 14th due in the coming months. She said: "It is not taken seriously enough. It seems to be that we are just not being heard at the minute." Watch video Source: BBC News, 9 September 2021
  4. Content Article
    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’.
  5. Content Article
    The aim of this qualitative study, published in Midwifery, was to examine how (UK and Australian based) midwifery students, who self-identify as having been bullied, perceive the repercussions on women and their families.
  6. Content Article
    This is the transcript of a Westminster Hall debate in the House of Commons on Black Maternal Health Awareness Week, dedicated to raising awareness about the disparities in maternal outcomes for Black women.
  7. Content Article
    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. 
  8. Content Article
    "My voice didn't matter. I felt like I was being gas lit, and that I wasn't important." Black women report being dismissed and neglected by healthcare professionals throughout pregnancy, childbirth and beyond - and are four times more likely to die in childbirth than women of other ethnicities. Prominent medical committee, NICE, has proposed that inducing pregnant Black women, bringing their birth forward early, could go some way to addressing the problem. The host of this podcast from The Fourcast speaks to a doctor who says it’ll make birth safer for mums and babies, and campaigner Sandra Igwe who says that early induction is not the solution to a deep and complex issue, rooted in racism and inadequate healthcare for Black mothers-to-be.  *Content warning: This episode includes discussion about maternal death and stillbirth.
  9. Content Article
    Getting It Right First Time (GIRFT) is designed to improve the quality of care within the NHS by reducing unwarranted variations. By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings.
  10. Content Article
    The 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.
  11. Content Article
    Knowing your rights and the law in pregnancy and childbirth is important. The charity Birthrights has produced a series of factsheets to provide you with the latest information on your rights, where they come from in law, and how they are backed up in guidance.
  12. Content Article
    Do all your staff receive training for the management of anaphylaxis as part of their mandatory training? Do you have a specific maternal cardiac arrest emergency call to include obstetricians and neonatologists? Do all resuscitation trolleys in your trust have a scalpel and umbilical cord clamps as an essential kit requirement? Are you aware of the obstetric cardiac arrest quick reference guide from the Resus Council, OAA and MBRRACE? Obstetric cardiac arrest is rare but devastating. This quick reference guidance, produced by Resuscitation Council UK and Obstetric Anaesthetists’ Association (and endorsed by MBRRACE), has been developed to aid Advanced Life Support providers response to this. It aims to help structure the team response, with reminders of modifications required for the pregnant patient and causes of cardiac arrest to consider.
  13. Content Article
    Preventable harm during labour can be catastrophic for parents, babies and families, as well as for the staff involved. Reducing avoidable brain injury in childbirth means building on everyone’s experiences and expertise, working together to improve care in labour for all. THIS Institute, in partnership with The Royal College of Midwives and The Royal College of Obstetricians & Gynaecologists, is inviting maternity staff, parents and birth partners from across the UK to contribute their views to their Avoiding Brain Injury in Childbirth (ABC) campaign. The focus is on monitoring and responding to babies’ wellbeing during labour and on managing the emergency complication at caesarean section known as impacted fetal head. The ABC campaign aims to give maternity staff tools and support to be able to provide the highest quality of care when there are concerns about the baby’s wellbeing during labour. It also aims to improve communication with everyone using maternity services and make sure they are listened to and involved in decisions about their care.
  14. Content Article
    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.
  15. Content Article
    In this blog, Farrah Pradhan, Project Manager for Clinical Quality, Education and Projects at RCOG, describes her work with maternity professionals, namely obstetricians, and through undertaking an MSc in Patient safety. Farrah’s focus was on their 'work as done' to see if the concepts of Safety-II (capability mindfulness and resilience engineering) helped them to work more safely.
  16. Content Article
    In December 2020, Ockenden Report: Emerging findings and recommendations from the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust, was published. The report set out seven immediate and essential actions for Trusts under the following themes: Enhanced safety Listening to women and families Staff training and working together Managing complex pregnancy Risk assessment throughout pregnancy Monitoring fetal wellbeing Informed consent The below infographic, produced by the University of Southampton NHS Foundation Trust, sets out their plans against each of the seven actions.
  17. News Article
    Women deserve better, say campaigners Women have voiced their frustration that a year since Baroness Cumberlege published her scathing First Do No Harm report the only thing the Government has achieved is a half-hearted apology from Matt Hancock. Politicians from all parties are meeting to call for action in a debate in Parliament on the one-year anniversary since the Cumberlege report was published https://firstdonoharmappg.org.uk/category/news/ The back-bench debate is on Thursday July, 8, and is being led by MP Emma Hardy and Shadow Health Minister Alex Norris. Emma Hardy, MP, chair of the All-Party Parliamentary Group (APPG) into mesh, said: “Women deserve better than the Government’s refusal to implement the Baroness Cumberlege recommendations. The recommendations will not only make life better for those living with mesh complications, they will also improve patient safety for everyone in the future.” The First Do No Harm report looked at the dismissive attitude towards women harmed by mesh implants, and also women and their babies harmed by Primodos pregnancy testing drug and epilepsy drug Sodium Valproate. Primodos was discontinued in the 1970s. Sodium Valproate is still used today and there are fears women are still not being warned of the risks to their unborn baby if they take it during pregnancy. The debate is calling for all Cumberlege recommendations to be implemented without further delay, including financial redress for women and sweeping reform of the healthcare and regulation framework. It is also calling for a retrospective audit of mesh to work out the number of women suffering. The Cumberlege report suggests contacting all women who had mesh in the year 2010 to see how they are in 2021. Kath Sansom, founder of campaign group Sling The Mesh, which has 9,000 members, said: “Mesh for stress incontinence was suspended in 2018 and we believe it should not be brought back until the audit is carried out until we know the true scale of complications. Scottish Government have pledged to never bring it back. Sadly, surgeons in England are pushing for it to be used again.” Included in the recommendations is a call for industry to declare all monies and gifts to doctors, teaching hospitals and research institutions. Kath said: “In post pandemic times it is more important than ever to know who is funding our research and prescribing decisions. In America there is a Sunshine Payment Act, forcing healthcare giants, who make billions in profits, to declare all the money and non-financial gifts they hand out. It has been proved such funding leads to bias in prescribing and bias in the scientific research. We need this legislation for the UK. That way campaigners and patients can see who is funding a doctor’s voice.” Meantime, in Northern Ireland and Wales, mesh injured women have been left virtually high and dry and will be looking to the debate for hope. Susan McLarnon of Sling The Mesh Northern Ireland, said: “Mesh services are next to non-existent. No formal announcement has been made since the new centres opened on 1st April. Patients who are lucky enough to get a gynaecology appointment are still being told mesh isn’t the issue. They are still in denial. Women have been left in limbo. Suffering horrendous pain with nowhere to turn. Some are being told to complain to their MP yet nobody is listening to us.” Karen Preater, of Mesh Awareness Wales, added: “Other than when the Cumberlege report came out, there has been no statements or correspondence, I have emailed several times asking about a Patient Safety Commissioner and have had no responses. South Wales have their centre. North Wales are told to use Manchester. Total silence from the Welsh Government.” The Parliamentary debate will look at the black hole in official statistics, which means nobody knows how many women have been harmed. Kath said: “We are deeply concerned about a significant discrepancy between NHS figures and surgeon data on mesh complications – we fear surgeons have downplayed complications by almost ten times. The truth is nobody knows the scale of this women’s health scandal and the only way to get to the bottom of it is a retrospective audit.” See the question to Parliament on discrepancy of the figures about the number of women suffering here: https://questions-statements.parliament.uk/written-questions/detail/2021-03-04/163289 USEFUL LINKS BLOG by MP Emma Hardy: Mesh surgery is costing the NHS millions https://www.emmahardy.org.uk/2018/04/18/mesh-surgery-failure-is-costing-the-nhs-millions-of-pounds/
  18. News Article
    A call for action on the one-year anniversary since the Cumberlege report was published will be happening in Parliament today and is being led by MP Emma Hardy and Shadow Health Minister Alex Norris. Emma Hardy, chair of the All-Party Parliamentary Group (AAPG) has said “Women deserve better than the Government’s refusal to implement the Baroness Cumberlege recommendations. The recommendations will not only make life better for those living with mesh complications, they will also improve patient safety for everyone in the future.” Read full story. Source: Medical Plastics News, 07 July 2021
  19. News Article
    Baroness Julia Cumberlege has said she is angry and frustrated at the lack of progress being made after she led a critical review into how the health service treats female patients. During her review, she spent 2 years speaking to 700 women and their families who experienced complications linked to two drug treatments and a medical device. The four UK governments are still considering her recommendations and say they will respond fully later this year. Read full story. Source: BBC News, 08 July 2021
  20. Content Article
    Neonatal herpes is a rare, and potentially fatal, disease which usually occurs in the first four weeks of a baby's life. It is caused by the same virus that causes cold sores and genital infections – the herpes simplex virus (HSV).  In this blog, Sarah de Malplaquet, Chief Executive and Founder of the Kit Tarka Foundation, draws on her own devastating experience of her son dying to illustrate why healthcare staff with cold sores must stay away from new babies. Sarah highlights the lack of awareness of the dangers and calls for a widespread review of policy in order to prevent future deaths. 
  21. Content Article
    Surgical site infection (SSI) is one of the most common complications following cesarean section, and has an incidence of 3%–15%. It places physical and emotional burdens on the mother herself and a significant financial burden on the health care system. SSI is associated with a maternal mortality rate of up to 3%.  This paper, published in the International Journal of Women's Health, focuses on: Risk factors Prevention strategies Intraoperative practices Post operative assessment.
  22. Content Article
    This report provides an update on overall progress in meeting the National Maternity Safety Ambition and implementing the range of initiatives designed to improve outcomes for mothers and babies since 2015.  Content includes: Progress on National Ambition outcomes What has been achieved? Changing culture Specific safety initiatives System enablers Next steps.
  23. Content Article
    This study, published in the Journal of family planning and reproductive health care, aimed to determine the prevalence of and reasons for and against the use of local anaesthesia (LA) for IUD insertion. The results suggest that more UK health professionals need to routinely discuss pain relief and offer this to their patients prior to IUD insertion as part of the care pathway for patients who choose to use intrauterine contraception.
  24. Content Article
    There have been many testimonials from patients who have experienced high levels of pain during intrauterine device (IUD) insertion. This has gained media attention and led to calls for better pain management options and informed consent processes. This study, published in Contraception, investigated if providers accurately assess pain during IUD insertion. Authors concluded that providers underestimate pain during IUD insertion.
  25. Content Article
    The Valporate Safety Implementation Group (VSIG) is a clinically-led group set up to help facilitate the reduction of the use of sodium valporate in women and girls where there is a safer alternative.
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