1. Safety and Quality in Maternity Care
Denise Boulter
Midwife Consultant
Public Health Agency

2. How safe is the health service?

3. What we aspire to
What we sometimes get

4. How Hazardous Is Health Care? (Leape)

5. How Hazardous is Maternity Care
25,000 births
Perinatal mortality lowest for 10 years
Maternal death very uncommon
However!!!!!
Approximately 20 Serious Adverse Incidents reported
Over 150 Complaints regarding maternity services
2012 NHS compensation bill exceeded £1 billion pounds
20% all claims are maternity 49% payout is for maternity

6. Public Health Agency Functions
Health Protection
surveillance; health care infection; patient safety; patient experience, emergency planning; pandemic ‘flu
Health Improvement
Inequalities; public awareness; local interventions; partnerships; user involvement
Commissioning & Screening
Regional & local commissioning; public health priorities; wider influence; screening services
Research & Development

7. PHA Commissioning Role
Provide high quality independent professional and public health advice to support commissioning
Lead on commissioning and service improvement of agreed areas of work
Regional Board
Must consult PHA and have due regard for advice or information provided
Must not publish a commissioning plan without PHA approval
LCGs
Legislation requires LCGs to work in collaboration with PHA

8. “New Rules” for Health Care
Safety as a system property
The need for transparency and effective reporting – information a tool rather than a trial.
Testing the systems and the staff
More rapid response when things go wrong
Tracking and providing feedback about adverse events
Increased Cooperation

9. Issues There are serious problems in quality
Between the health care we have and the care we could have, lies not just a gap but a chasm.
The problems come from poor systems…not bad people
The question is why have we not sorted it to date?
We can fix it… but it will require changes

10. The First Law of Improvement
Every system is perfectly designed to achieve exactly the results it gets.
‘The principal failure lay in
not collecting together those pieces of evidence.’

11. Ingredients Practice Evidence based Care Pathways Consistent processes
Education & training
People
Person Centred Service
Safety Forum
Support and challenge
Education and training

13. People You are the key ingredient in making patients safe.
What can I do?
Communicate
Report incidents
Open and honest culture
Contribute to risk assessments and audit
Put safety top of your priorities – ‘ do no harm
Ask for help
Don’t take short cuts
Legible writing

14. Priorities Strategy Implementation / Development
Maternity Strategy for Northern Ireland
Midwifery 2020
Maternity Quality Improvement group
Maternity Hand Held Record
Regional Learning Letters

15. When it goes wrong Death of Savita Hallappanavar
Failure to recognise she was ill
The most basic means of identifying any patients at risk of clinical deterioration is to observe the patient and regularly monitor and track her clinical observations
Lack of learning from previous similar case
2008 Tanya Mc Cabe
The hospital should invest in a physiological observation track and trigger system that promotes the early recognition of patient deterioration and appropriate intervention

16. Serious Adverse Incidents
Definition of an adverse incident:
‘Any event or circumstances that could have or did lead to harm, loss or damage to people, property, environment or reputation’. arising during the course of the business of a HSC organisation / Special Agency or commissioned service

17. SAI criteria
 Serious injury to, or the unexpected/unexplained death of:
a service user
a staff member in the course of their work
a member of the public whilst visiting a HSC facility.
Any death of a child (up to eighteenth birthday) in a hospital setting.
Unexpected serious risk to a service user and/or staff member and/or member of the public
Unexpected or significant threat to provide service and/or maintain business continuity
Serious self-harm or serious assault (including homicide and sexual assaults) by a service user, a member of staff or a member of the public within a healthcare facility
Suspected suicide of a service user known to Mental Health services (including Child and Adolescent Mental Health Services, (CAMHS) and Learning Disability (LD) within the last year.
Serious self-harm / serious assault (including homicide and sexual assaults) by a service user in the community who is known to mental health services (including CAMHS) or learning disability services within the last year.
on themself
on other service users,
on staff or
on members of the public
Serious incidents of public interest or concern relating to:
any of the criteria above
theft, fraud, information breaches or data losses
a member of HSC staff or independent practitioner

18. QUALITY, SAFETY AND EXPERIENCE SAFETY QUALITY ALERT TEAM SERIOUS ADVERSE INCIDENTS COMPLAINTS

19. Myths
The perfection myth – if we all try hard enough we will not make any mistakes
The punishment myth – of we punish people when they make mistakes they will make fewer.

20. The reality
We all make errors, no matter how much training and experience we process, or how motivated we are to do right.

21. To cover up is unforgivable To fail to learn is inexcusable
The Message
To err is human
To cover up is unforgivable
To fail to learn is inexcusable
While the evidence ogf the link between nurse staffing and patient safety is clear – Why hasn't nursing been given a higher priority on a national safety agendas.
Much of the attention has been on preventing errors but less on the latent conditions that increase the risk of errors –
The evidenc is there – Safe nurse staff – is sfae pateint care
There is evidence that if you address the latent causes then you will have a greater impact on safety and at a greater speed.

22. Ensure that the urgent doesn’t crowd out the important
ALWAYS
Ensure that the urgent doesn’t crowd out the important