5 How Hazardous is Maternity Care 25,000 birthsPerinatal mortality lowest for 10 yearsMaternal death very uncommonHowever!!!!!Approximately 20 Serious Adverse Incidents reportedOver 150 Complaints regarding maternity services2012 NHS compensation bill exceeded £1 billion pounds20% all claims are maternity 49% payout is for maternity
6 Public Health Agency Functions Health Protectionsurveillance; health care infection; patient safety; patient experience, emergency planning; pandemic ‘fluHealth ImprovementInequalities; public awareness; local interventions; partnerships; user involvementCommissioning & ScreeningRegional & local commissioning; public health priorities; wider influence; screening servicesResearch & Development
7 PHA Commissioning Role Provide high quality independent professional and public health advice to support commissioningLead on commissioning and service improvement of agreed areas of workRegional BoardMust consult PHA and have due regard for advice or information providedMust not publish a commissioning plan without PHA approvalLCGsLegislation requires LCGs to work in collaboration with PHA
8 “New Rules” for Health Care Safety as a system propertyThe need for transparency and effective reporting – information a tool rather than a trial.Testing the systems and the staffMore rapid response when things go wrongTracking and providing feedback about adverse eventsIncreased 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 peopleThe 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 innot collecting together those pieces of evidence.’
11 Ingredients Practice Evidence based Care Pathways Consistent processes Education & trainingPeoplePerson Centred ServiceSafety ForumSupport and challengeEducation and training
13 People You are the key ingredient in making patients safe. What can I do?CommunicateReport incidentsOpen and honest cultureContribute to risk assessments and auditPut safety top of your priorities – ‘ do no harmAsk for helpDon’t take short cutsLegible writing
14 Priorities Strategy Implementation / Development Maternity Strategy for Northern IrelandMidwifery 2020Maternity Quality Improvement groupMaternity Hand Held RecordRegional Learning Letters
15 When it goes wrong Death of Savita Hallappanavar Failure to recognise she was illThe most basic means of identifying any patients at risk of clinical deterioration is to observe the patient and regularly monitor and track her clinical observationsLack of learning from previous similar case2008 Tanya Mc CabeThe 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 usera staff member in the course of their worka 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 publicUnexpected or significant threat to provide service and/or maintain business continuitySerious 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 facilitySuspected 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 themselfon other service users,on staff oron members of the publicSerious incidents of public interest or concern relating to:any of the criteria abovetheft, fraud, information breaches or data lossesa member of HSC staff or independent practitioner
18 QUALITY, SAFETY AND EXPERIENCE SAFETY QUALITY ALERT TEAM SERIOUS ADVERSE INCIDENTS COMPLAINTS
19 MythsThe perfection myth – if we all try hard enough we will not make any mistakesThe punishment myth – of we punish people when they make mistakes they will make fewer.
20 The realityWe 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 MessageTo err is humanTo cover up is unforgivableTo fail to learn is inexcusableWhile 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 careThere 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 ALWAYSEnsure that the urgent doesn’t crowd out the important