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EventDuring pregnancy, labour and delivery many First Nations, Inuit and Métis people experience significant barriers to accessing care thus leading to unacceptable health disparities including increased risk for poor maternal and newborn health outcomes in Canada. There are opportunities to improve maternal and infant health outcomes. Join this webinar with the National Aboriginal Council of Midwives and Patients for Patient Safety Canada, a patient-led program of Healthcare Excellence Canada, in honour of World Patient Safety Day. The goals of this virtual discussion are to build awareness and understanding of the experiences of First Nations, Inuit and Métis, and to discuss ways to provide safer maternal and newborn care. The perspectives and experiences of patients, providers and researchers on the current patient safety challenges will be shared, as well as the supports and strategies to improve outcomes and experiences. This session will also identify what health care providers and leaders can do to improve First Nations, Inuit and Métis safety and health outcomes. All will leave the session practical ideas to improve patient safety with and for Indigenous families. Register
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EventRegister
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EventWHO Patient Safety Flagship invites you to participate in World Patient Safety Day 2021 Virtual Global Conference “Together for safe and respectful maternal and newborn care” The conference will be opened by WHO leadership and will feature: Keynote addresses by global patient safety leaders and advocates. Global landscape and stories from the ground on maternal and newborn health and safety. Panel discussions on prioritizing safety in maternal and newborn care in the journey towards universal health coverage and the role of partners. Introduction of World Patient Safety Day Goals 2021. World Patient Safety Day 2021 is dedicated to “Safe maternal and newborn care” recognising the significant burden of avoidable harm women and newborns are exposed to due to unsafe care, particularly around the time of childbirth. Registration
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EventuntilThe World Patient Safety Day (WPSD) is observed globally on 17 Sept every year. The objectives of WPSD are to increase public awareness and engagement, enhance global understanding, and work towards global solidarity and action by all stakeholders to improve patient safety. The theme of WPSD 2021 is “Safe maternal and newborn care". WPA has initiated a campaign to celebrate WPSD all over the world. As part of this campaign, WPA is organising a regional webinar series in September 2021. WPA will conduct webinars in EURO, Asia Including EMRO, Latin America and AFRO Region. Monday 6 September 2021 - WPSD Regional Webinar for EURO Thursday 9 September 2021 - WPSD Regional Webinar for Latin America Monday 13 September 2021 - WPSD Regional Webinar for Asia including EMRO Tuesday 14 September 2021 - WPSD Regional Webinar for AFRO
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EventThis webinar will focus on how to harness the vast experience of the voluntary sector and advocate locally appropriate strategies to improve patient safety, through a network of Ambassadors. Who should attend? Patient safety can only be achieved by collaboration between the professionals, patients, families, community members and stake holders. So, whatever your background you are most welcome. Objectives To raise awareness about the burden of unsafe health care. To bring together the voluntary sector with a stake in health improvement programmes, to adopt a charter for patient safety and integrate safety strategies into their programmes. Speakers Neelam Dhingra, Unit Head, WHO Patient Safety Flagship/A Decade of Patient Safety 2020-2030, World Health Organization, Geneva Dr. Abdulelah Alhawsawi, Global Ambassador, The G20 Health and Development Partnership; Former Director General, Saudi Patient Safety Centre Dr. Zakiuddin Ahmed Founder, Riphah Institute of Healthcare Improvement & Safety and Healthcare Quality & Safety Association of Pakistan Ms Regina N. M Kamoga, Executive Director, CHAIN Uganda Register
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EventuntilThis event will mark the 2021 World Health Organisation’s World Patient Safety Day and aims to showcase the patient safety work happening in the NHS and with partners, to improve the safety of maternal and neonatal care. Speakers: Introduction from Aidan Fowler, National Director of Patient Safety (chair) Presentations from the National Maternity Champions, Matthew Jolly, National Clinical Director for Maternity and Women's Health and Professor Jacqueline Dunkley-Bent OBE, Chief Midwifery Officer Hear from AQUA (the Advancing Quality Alliance) about its safety culture programme for maternity and neonatal board safety champions Dr Nicola Mackintosh, Associate Professor in Social Science Applied to Health, SAPPHIRE Deputy, University of Leicester will present on ‘What a good maternity safety culture looks like’, providing an overview of a considered analysis of maternity and neonatal safety culture surveys Tony Kelly, National Clinical Lead for the Maternity and Neonatal Safety Improvement Programme will provide an introduction to the national Maternity Early Warning Score (MEWS) tool and Newborn Early Warning Trigger and Track (NEWTT) Expected Audience: NHS provider and commissioning staff, particularly those working in maternity and neonatal care and in patient safety roles. Register
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Content ArticleGlobal landscape in maternal and newborn health (Dr Anshu Banerjee - Director, Department of Maternal, Newborn, Child and Adolescent Health and Ageing at the WHO) Respectful childbirth for all women and newborns (Dr Ian Askew - Director, Department of Sexual and Reproductive Health and Research at the WHO) Towards eliminating avoidable harm in maternal and newborn care: launch of World Patient Safety Day goals 2021 (Dr Neelam Dhingra - Unit Head, Patient Safety Flagship at the WHO) Maintaining safe functioning of maternal and newborn services during the COVID-19 pandemic (Dr Rudi Eggers - Director, Integrated Health Services at the WHO) Economics of patient safety (Professor Niek Klazinga - Head of the OECD Health Care Quality Indicator Programme)
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Content ArticlePReCePT (prevention of cerebral palsy in preterm labour) offers magnesium sulphate to eligible women during preterm labour, reducing the risk of a pre-term baby developing cerebral palsy by 50%. This HSJ Patient Safety Award-winning intervention led to 850 additional mothers in preterm labour receiving magnesium sulphate in 2019/20, avoiding an estimated 30 cases of cerebral palsy. The learning from the spread of PReCePT to all maternity units in the West of England was adopted as national safety improvement programme, leading to increased uptake across England. PERIPrem (Perinatal Excellence to Reduce Injury in Premature Birth) is a new perinatal care bundle improving outcomes for premature babies across the West of England and South West AHSN regions. The bundle consists of a number of interventions that can have a significant impact on brain injury and mortality rates amongst babies born prematurely. The project has been co-produced with parent partners, with specific resources developed to ensure parents are the agents of their premature baby’s care. ‘Place of birth’. The Oxford AHSN Maternity Network brought together stakeholders from across the region, so that more extremely premature babies are born in a Level 3 unit that can provide more specialist care. This required a significant shift in working practices from making decisions based on availability of beds and staff, to focus on the risks for the mother and baby. The initiative has led to an increase in eligible babies born in a Level 3 unit from 50% to around 75-80%, and it is estimated that the lives of four more extremely premature babies are being saved every year, a 5% increase. Unlike mainstream emergency medicine, there is currently no standardised triage system within maternity for unscheduled appointments. The Birmingham Symptom-specific Obstetric Triage System (BSOTS) was co-produced in 2013 by midwives and obstetricians from Birmingham Women’s and Children’s NHS Foundation Trust and the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC). BSOTS is now in 25 maternity units across the UK and approximately 33,000 women have been assessed sooner. MatNeo Safety Improvement Programme contributes to two key national ambitions: to reduce the rates of maternal and neonatal deaths, stillbirths and brain injuries that occur during or soon after birth by 50% by 2025 (as set out in Better Births), and to reduce the national rate of preterm births from 8% to 6% (as set out in Safer Maternity Care).
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The Patients Association: World Patient Safety Day 2021
Patient Safety Learning posted an article in Maternity
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World Patient Safety Day 2021
Patient Safety Learning posted an article in Maternity
Today marks the third annual World Patient Safety Day. Established by the World Health Organization (WHO) in 2019, this is intended as a day to help enhance understanding of patient safety and to engage the public in this, promoting actions to improve safety and reduce avoidable harm.[1] Patient safety and the impact of unsafe care The NHS describes patient safety as ‘the avoidance of unintended or unexpected harm to people during the provision of healthcare’.[2] The WHO in their definition expand on this, adding that it also involves ‘continuous improvement based on learning from errors and adverse events’.[3] So, how big of a problem is avoidable harm in healthcare? WHO estimates that unsafe care is 1 of the 10 leading causes of death and disability worldwide.[4][1] It is a huge problem, with devastating consequences for patients around the world: Unsafe care results in over 3 million deaths each year worldwide.[5] It is forecast to cost the global economy approximately $383.7 billion by 2022.[5] This also comes with an untold physical and emotional impact on those affected, in addition to a loss of trust in the healthcare systems by patients, and a loss of morale and frustration among healthcare professionals at not being able to provide the best possible care. It has been described by the G20 Health and Development Partnership as ‘the overlooked pandemic’.[5] How do we improve patient safety? A growing recognition of the need to make significant improvements to patient safety emerged in the 1980s and 1990s. Subsequently, in the last twenty years, there have been many international and national initiatives to better understand the causes of unsafe care and the action needed to reduce harm. But despite the good work of many people over this time, avoidable harm in healthcare remains a persistent, wide-scale problem. At Patient Safety Learning, we recognise that the main causes of unsafe care are systemic. Avoidable harm has complex roots and to make real progress we need to address these underlying systems issues. We believe that there needs to be a transformation in our approach to tackling this problem. Key to this is patient safety being treated as core to the purpose of health and social care, not as one of several competing priorities to be traded off against each other. In our report, A Blueprint For Action, we set out an evidence-based analysis of why harm is so persistent and what is needed to deliver a patient safe future, identifying six foundations of safe care:[6] Shared Learning - organisations should set and deliver goals for learning, report on progress and share their insights widely for action. Leadership - we emphasise the importance of overarching leadership and governance for patient safety. Professionalising patient safety - recognising that organisational standards and accreditation for patient safety need to be developed and implemented. These need to be used by regulators to inform their assessment of safe care. Patient Engagement - to ensure patients are valued and engaged in patient safety. Data and Insight - better measurement and reporting of patient safety performance, both quantitative as well as qualitative. Just Culture - all organisations should publish goals and deliver programmes to eliminate blame and fear, introduce or deepen a Just Culture, and measure and report progress. This year’s theme: Safe maternal and newborn care Maternal and newborn care, the focus of this year’s World Patient Safety Day, is an area of healthcare that is particularly susceptible to risk. Approximately 810 women die every day from preventable causes related to pregnancy and childbirth.[1] In addition, around 6700 newborns die every day, amounting to 47% of all under-5 deaths.[1] Moreover, about 2 million babies are stillborn every year, with over 40% occurring during labour.[1] There is a significant gap between countries in this regard, with 94% of all global maternal deaths occurring in low- and middle-income countries.[7] Although outcomes are better in high-income countries, patient safety concerns are consistently high within maternity services, demonstrated by the many major inquiries and reviews in the UK in recent years.[8-12] Some key issues raised in these recent reports include: Lack of informed consent, with patients not being provided with all the information about what treatment involves, including benefits and risk. Persistence of a blame culture, discouraging staff from speaking up about unsafe care. Failure to listen and act on concerns raised by patients and family members. Barriers to and problems with multidisciplinary working in maternity care. Lack of support for patients after unsafe care. Unsafe staffing levels. Four key objectives WHO has set out four key objectives for this year’s World Patient Safety Day: Raise global awareness on the issues of maternal and newborn safety, particularly during childbirth. Engage multiple stakeholders and adopt effective and innovative strategies to improve maternal and newborn safety. Call for urgent and sustainable actions by all stakeholders to scale up efforts, reach the unreached, and ensure safe maternal and newborn care, particularly during childbirth. Advocate the adoption of best practices at the point of care to prevent avoidable risks and harm to all women and newborns during childbirth. Highlighting safety issues and sharing good practice To mark this year’s World Patient Safety Day, we are highlighting some key areas of concern and good practice in relation to maternal and newborn safety, sharing insights, resources, and experiences on our award-winning patient safety platform, the hub, including: Top picks: 7 key resources for maternity safety Blog: Maternal care and safety in low- and middle-income countries Event: WHO - World Patient Safety Day 2021 Virtual Global Conference Resources: The maternity section of the hub Do you have an experience to share around maternity safety, as a pregnant woman or birthing person? Or perhaps you are a healthcare professional looking to share your frontline insights to help improve safety? Join the conversation in our community forum on the hub, or get in touch with us by emailing content@pslhub.org. References WHO, World Patient Safety Day 2021, Last Accessed 12 September 2021. NHS England and NHS Improvement, Patient Safety, Last Accessed 12 September 2021. WHO, Patient Safety, Last Accessed 12 September 2021. WHO, Patient Safety Fact File, September 2019. The G20 Health and Development Partnership and RLDatix, The Overlooked Pandemic: How to transform patient safety and save healthcare systems, 25 March 2021. Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019. WHO, Maternal Mortality, 19 September 2019. Dr Bill Kirkup, The Report of the Morecambe Bay Investigation, 2015. The Royal College of Midwives and Royal College of Obstetricians and Gynaecologists, Review of Maternity Services at Cwm Taf Health Board, 30 April 2019. The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020. Dr Bill Kirkup CBE, The Life and Death of Elizabeth Dixon: A Catalyst for Change, November 2020. Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Emerging findings and recommendations form the independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, 10 December 2020. -
Content ArticleThe 17 September marks World Patient Safety Day, and this year the focus is on ‘Safe maternal and newborn care’. Patient Safety Learning has recently published a blog highlighting and summarising this topic.[1] While issues of unsafe care are a global challenge, they disproportionately impact on low- and middle-income countries. 134 million adverse events occur in hospitals every year in such countries, contributing to 2.6 million deaths.[2] Research in patient safety has primarily been associated with high income countries, but more recently there has been greater attention on low- and middle-income countries due to the global awareness of the need to improve patient safety standards for all patients, including maternal care.[3] Worldwide, around 295,000 women died during and following pregnancy and childbirth in 2017.[4] Approximately 810 women and 6,700 newborns die every day from preventable causes related to pregnancy and childbirth.[5] These global statistics are shocking and highlight the attention that is needed to address maternal safety. Of all the global maternal deaths, 94% occur in low- and middle-income countries.[4] This reflects inequalities in access to quality health services and highlights the global gap between rich and poor.[3] Of the many health statistics monitored by the World Health Organization (WHO), the largest gap between rich and poor nations is seen in maternal mortality levels.[7] Sub-Saharan Africa and Southern Asia accounted for approximately 86% of the estimated global maternal deaths in 2017.[4] Adolescent girls are more likely than older women to die due to complications related to pregnancy and childbirth; this is the leading cause of death for adolescent girls in low- and middle-income countries.[8] Infants also suffer greatly – of the approximate 8 million infant deaths each year, around two-thirds occur in the first month of life in low income countries.[6] Moreover, about 2 million babies are stillborn every year, with over 40% occurring during labour.[5] Maternal deaths occur as a result of complications that can transpire during and following pregnancy and childbirth, most of which are preventable or treatable.[4] The major complications that account for nearly 75% of all maternal deaths include severe bleeding after childbirth, infections and pre-eclampsia.[4] Additionally, for every woman who dies, at least 30 others are injured, often in disabling and socially devastating ways.[8] For example, obstetrical fistula is common in poor communities in sub-Saharan Africa and South Asia, where access to maternal health services is limited.[9] Most of neonatal and perinatal deaths are the result of poor maternal health and inadequate care during pregnancy and delivery and the critical immediate postpartum period.[6] The main factors that prevent women from receiving or seeking care during pregnancy and childbirth in low- and middle-income countries are poverty, distance to facilities, lack of information, inadequate and poor-quality services, and cultural beliefs/practices.[4] For instance, 35% of Senegalese women who live in rural areas deliver their children at home, often without a skilled midwife or birth attendant present, which poses dangers to both mother and child.[7] Care by trained staff is vital in preventing maternal deaths in low-income countries, yet only about half of births in such countries occur in health facilities.[9] Poor person-centred maternity care (PCMC) is one of the main factors driving both the low proportions of facility-based deliveries and high maternal mortality.[8] There is also a strong connection between the low societal status of women in low income countries and the risk of maternal illness and death.[6] The reality is that most maternal deaths are preventable, as the healthcare solutions to prevent or manage complications before, during and after childbirth are well recognised. It is particularly important that all births are attended by skilled health professionals because timely management and correct treatment can preserve the life of both mother and baby.[4] To improve maternal health in low- and middle-income countries, barriers that limit access to quality maternal health services must be identified and addressed at both health system and societal levels.[4] While additional resources are essential to patient safety improvement in low-income settings, such resources on their own will not be enough to secure the changes needed.[9] Recognising the scale of this problem, improving maternal health is now one of WHO’s key priorities.[6] Whilst many other health indicators have improved over the last two decades, maternal mortality rates in low- and middle-income countries have remained high and progress in reducing maternal and newborn mortality has been very slow.[8] Unsafe maternal care represents a serious and considerable danger to patients in low income countries – primarily due to scarce resources, weak infrastructure, cultural beliefs and limited skilled professionals – hence it should be a high priority public health problem that needs drastic attention.[10] References Patient Safety Learning. Safe maternal and newborn care: World Patient Safety Day 2021. The G20 Health and Development Partnership and RLDatix. The Overlooked Pandemic: How to transform patient safety and save healthcare systems, 2021. Elmontsri M, Banarsee R, Majeed A. Improving patient safety in developing countries – moving towards an integrated approach. JRSM Open, 2020; 9(11). World Health Organization. Maternal mortality, 2019. World Health Organization. World Patient Safety Day 2021, 2021. Donnay, F. Maternal survival in developing countries: what has been done, what can be achieved in the next decade. Gynecology & Obstetrics, 2000; 70(1). Plan International. What pregnancy looks like in 10 developing countries, 2018. Rosenfield A, Min C, Freedman L. Making Motherhood Safe in Developing Countries. The New England Journal of Medicine, 2007; 356:1395-1397. Aveling E, et al. Why is patient safety so hard in low-income countries? A qualitative study of healthcare workers’ views in two African hospitals. BMC, 2015; 11(6). Wilson R, et al. Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital. BMJ, 2012; 344.
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We are now just under three weeks away from the third annual World Patient Safety Day, organised by the World Health Organization (WHO), set to take place on Friday 17 September 2021. The theme of this year’s World Patient Safety Day is ‘Safe maternal and newborn care’. Patient safety concerns relating to maternity services have been particularly prominent in the UK in recent years, with serious failings highlighted by the Cumberlege Review, Dixon Inquiry and the ongoing Ockenden Maternity Safety Review. In the run up to the 17 September, WHO has been highlighting some key global statistics around this:[1] 810 women every day die because of preventable causes related to pregnancy and childbirth. Around 6,700 newborns die each day, amounting to 47% of all under-5 deaths. About 2 million babies are stillborn every year, with 40% occurring during labour. WHO’s objectives are to raise awareness of these safety issues, engaging stakeholders to take action to improve maternal and newborn safety and advocate for the adoption of good practice at the point of care to prevent avoidable risks and harm. Highlighting safety issues and sharing good practice As World Patient Safety Day approaches, we will be highlighting some key areas of concern in relation to maternal and newborn safety, sharing insights, resources, and experiences on our award-winning patient safety platform, the hub. We will also be seeking to highlight examples of good patient safety practice. Below are two specific areas where we have a number of maternity safety resources already available on the hub: Neonatal herpes – we have shared a series of blogs by Sarah de Malpaquet, Chief Executive and Founder of the Kit Tarka Foundation, which raises awareness of neonatal herpes, funding research and providing advice to healthcare professionals and the public. Neonatal herpes – more common than you think? The devastating consequences of a missed neonatal herpes diagnosis Neonatal herpes: Why healthcare staff with cold sores should not be working with new babies Midwifery Continuity of Carer – we have a growing set of resources about this model of care, focused on the idea that women and birthing people should have continuity of the person looking after them during their maternity journey, before, during and after birth. Midwifery What does good look like? A presentation from the National Midwifery Lead for Continuity of Care. Frontline insights - A video with three midwives sharing their experiences of the continuity of carer way of working. “Embrace the journey” - Interview with a Consultant Midwife. The benefits of Continuity of Carer - A midwife’s personal reflections on this. Ahead of World Patient Safety Day we will seek to highlight more resources in this area in addition to other key patient safety issues. Share your experience on the hub Do you have an experience to share around maternity safety, as a pregnant woman or birthing person? Or perhaps you are a healthcare professional looking to share your frontline insights to help improve patient safety? Join the conversation in our community forum on the hub, or get in touch with us by emailing content@pslhub.org. References 1. Each of these statistics has been shared by the WHO here: WHO, World Patient Safety Day 2021, Last Accessed 26 August 2021. https://www.who.int/news-room/events/detail/2021/09/17/default-calendar/world-patient-safety-day-2021
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