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Showing results for tags 'Obstetrics and gynaecology/ Maternity'.
Found 398 results
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Content ArticleMaternity care continues to be associated with avoidable harm that can result in serious disability and profound anguish for women, their children, and their families, and in high costs for healthcare systems. To understand how to make maternity care safer, we must first understand what makes a maternity unit safe. Rather than focus on what goes wrong, this study from THIS.Institute focuses on what needs to go right by studying one high-performing maternity unit, located in Southmead Hospital in Bristol, UK.
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Content ArticleImperial College Healthcare NHS Trust maternity service provides care for around 10,000 babies and their mothers each year throughout pregnancy, labour, and the postnatal period. The Trust introduced the Cerner electronic patient record system including a maternity module for clinical documentation in 2014. Contractions and foetal and maternal heart rate are monitored using cardiotocograph (CTG) devices. Previously, the readings were printed out on rolls of paper. Midwives added handwritten clinical observations to these ‘foetal strips’ and used them to make critical decisions about the management of labour. These paper records were hard to share to quickly get a second opinion. They were prone to fading over time so did not always provide a permanent record and they were not integrated into the electronic patient records for our patients.
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Content ArticleIn the US, approximately 700 women die annually from pregnancy-related complications.The most frequent cause of severe maternal morbidity and preventable maternal mortality is obstetric haemorrhage — excessive blood loss from giving birth. As a result of this significant patient safety concern, The Joint Commission introduced two new standards, effective 1 July 2020, to address complications in maternal haemorrhage and severe hypertension/ preeclampsia. This Quick Safety provides background information around strategies for the management of maternal haemorrhage that are outlined in new Provision of Care, Treatment, and Services standard.
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Content ArticlePresentation from Mandy Townsend, Associate Director Patient Safety and co-lead for North West Coast Patient Safety Collaborative, at the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference held in Manchester on the 16 October 2019.
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Content ArticleConcern was raised about a number of deaths at Furness General Hospital leading to the establishment of the Morecambe Bay Investigation in September 2013, led by Dr Bill Kirkup. In May 2018 the Professional Standards Agency published a ‘Lessons Learned Review’ into the handling of concerns relating to the fitness to practise of nurses in Furness General Hospital (now part of the University Hospitals of Morecambe Bay NHS Foundation Trust) by the Nursing and Midwifery Council (NMC). Amongst other issues, the report identified problems with the handling of a document produced by the father of one of the babies who died at Furness General Hospital. In August 2018, the NMC commissioned Verita to carry out an independent audit to review the way the NMC handled the chronology. The audit was asked to focus on the NMC’s systems and processes in order to establish what happened to the chronology and to identify learning for the NMC from the case. Verita is a consultancy specialising in the management and conduct of investigations, reviews and inquiries. Peter Killwick and Kieran Seale carried out the investigation which was supported by Bethany Simpson.
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Content ArticleOperative vaginal birth is a common procedure used to expedite birth after full cervical dilatation where there is a clinical need to do so (15% of births in the UK in 2016). The acquisition of skills for operative vaginal birth is dependent on the exposure of junior obstetricians to situations in which they can undertake directly supervised learning.
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Content Article
HQCA: Patient Experience Awards 2019
Patient Safety Learning posted an article in Implementation of improvements
For the fourth year, the Health Quality Council of Alberta (HQCA), in partnership with the Patient and Family Advisory Committee (PFAC), held the Patient Experience Awards programme to recognise and help spread knowledge about initiatives that improve the patient experience in accessing and receiving healthcare services in Alberta, Canada. Applications spanned all corners of the province and came from a wide variety of care settings, and ranged from “elegantly simple” to complex in nature. The initiatives described reflected the diverse healthcare needs of Albertans and were equally diverse in their approach to healthcare improvement. However, they all had one thing in common: A desire to make change and deliver a better patient and family member experience. -
Content ArticleNHS Resolution has reported on the first year of its innovative scheme to drive improvements in maternity and neonatal services and to ensure that families are better supported whose babies suffer rare, but tragic, avoidable brain injuries at birth.
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Content ArticleThis case story is based on real events and NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. Although the case occurred in the emergency department there is learning for other departments. As you read about this incident, please ask yourself: Could this happen in my organisation? Who could I share this with? What can we learn from this?
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Content ArticleThis is a case study by NHS Resolution into recognising and avoiding significant maternal and neonatal hyponatraemia.
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Content ArticleThis case story is based on real events and NHS Resolution is sharing the experience to improve the quality of care provided to all patients, families and staff. This case study is around management of suspected maternal sepsis.
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Content ArticleThis leaflet draws attention to the number and cost of pressure ulcers suffered by women in maternity units. It provides information on common themes, their impact and what you can do to prevent them.
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Content ArticleThis report by NHS Resolution provides an in-depth examination of these rare but tragic incidents and the investigations that follow them. For the purposes of this study they focused on 50 cases of cerebral palsy where the incidents occurred between 2012 and 2016 and a legal liability has been established. Working in partnership with other organisations, including the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, NHS England and NHS Improvement, NHS Resolution have highlighted areas for improvement and made clear recommendations to help trusts prevent further incidents. The study draws upon the unique data set NHS Resolution holds to address two key areas for improvement: training to prevent future incidents and the quality of serious incident investigations.
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Content ArticleThis case story is based on real events; NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff.
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Content ArticleThis improvement resource set out by the National Quality Board is to help standardise safe, sustainable and productive staffing decisions in maternity services. This is an improvement resource to support staffing in maternity settings. It describes the principles for safe maternity staffing across the multiprofessional team to ensure women and their families receive joined-up care appropriate to their needs and wishes. The purpose of this resource is to help providers of NHS-commissioned services, boards and executive directors to support their head/director of midwifery and other lead professionals in implementing safe staffing for maternity settings. NHS provider boards are accountable for ensuring their organisation has the right culture, leadership and skills for safe, sustainable and productive staffing.
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Content ArticleA three-year programme launched in February 2017 to support improvement in the quality and safety of maternity and neonatal units across England - formerly known as the Maternal and Neonatal Health Safety Collaborative. NHS Improvement aim to: improve the safety and outcomes of maternal and neonatal care by reducing unwarranted variation and provide a high quality healthcare experience for all women, babies and families across maternity and neonatal care settings in England contribute to the national ambition, set out in Better Birthsopens in a new window of reducing the rates of maternal and neonatal deaths, stillbirths, and brain injuries that occur during or soon after birth by 20% by 2020.
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Content ArticleToolkit for improving perinatal safety helps hospital labour and delivery units in the US improve patient safety, team communication, and quality of care for mothers and their newborns with an aim of decreasing maternal and neonatal adverse events resulting from poor communication and system failures.
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Content ArticleThe neonatal practice development nurse and infant feeding midwife at Bedford Hospital NHS Trust led a programme of work to adopt and implement the ‘RAPP’ (Respirations, Activity, Perfusion, Position/Tone) tool in their maternity unit. This programme led to improved outcomes for new-born babies in the unit.
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Content ArticleThe Midwifery Matrons at Northampton General Hospital NHS Trust (NGHT) led on service development to address unwarranted variation in practices identified in complaints being made to the midwifery team. This has led to improved experiences and better use of resources within the Trust.
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Content ArticleThe findings of an independent investigation established to review the management, delivery and outcomes of care provided by the maternity and neonatal services of the University Hospitals of Morecambe Bay NHS Foundation Trust between January 2004 and June 2013.
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Content ArticleThis framework from NHS Improvement provides a structure for maternity units to create and develop their own approach to effectively communicating clinical data and transferring key safety information. It is intended as a good practice guide for healthcare professionals involved in the care of pregnant women and their infants, regardless of the nature of the unit they work in or whether it is in the community or a hospital. It recognises that each unit will have its own culture and ways of working.
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Content ArticleMind the Gap 2021 explores what training looked like for the maternity services workforce during the COVID-19 pandemic, and how this relates to the factors that contribute to the avoidable harm and deaths of mothers, birthing people, and their babies. It is an ongoing piece of research by the charity Baby Lifeline. The report directly surveys recommendations from reports investigating avoidable harm and takes into account wider events affecting maternity care. Training is a central recommendation for improving safety in maternity services. Gaps which already existed in training due to chronic underfunding and staff shortages have become worse, and this report will give recommendations to improve training nationally and locally at a critical time for maternity.
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Content ArticleIn 2015, the Royal College of Obstetricians and Gynaecologists established the Safer Women’s Health Care working party to identify the workforce and service standards needed to deliver safe, high-quality maternity and gynaecological care. This report is the output of the multi-disciplinary maternity standards work stream. It sets out a framework for commissioners and service providers of high-level maternity service standards that aim to improve outcomes and reduce variation in maternity care. There is also an accompanying framework for gynaecology services.
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Content ArticleLatest update of the Care Quality Commission's 'Inspection framework: Maternity Framework (Acute, community, independent)'.
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Content ArticleThis report from NHS England on the National Maternity Review sets out a vision for the planning, design and safe delivery of maternity services; how women, babies and families will be able to get the type of care they want; and how staff will be supported to deliver such care.
