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
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
PHA Commissioning Role PHA 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
“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
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
The First Law of Improvement Every system is perfectly designed to achieve exactly the results it gets.
Ingredients Practice Evidence based Care Pathways Consistent processes Education & training People Person Centred Service Safety Forum Support and challenge Education and training
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
Priorities Strategy Implementation / Development Maternity Strategy for Northern Ireland Midwifery 2020 Maternity Quality Improvement group Maternity Hand Held Record Regional Learning Letters
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
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
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
QUALITY, SAFETY AND EXPERIENCE SAFETY QUALITY ALERT TEAM SERIOUS ADVERSE INCIDENTS COMPLAINTS
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.
The reality We all make errors, no matter how much training and experience we process, or how motivated we are to do right.
To err is human To cover up is unforgivable To fail to learn is inexcusable The Message
ALWAYS Ensure that the urgent doesn’t crowd out the important