Towards more secure maternity care NPSA activities

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Towards more secure maternity mind NPSA activities Professor James Walker, Professor Obstetrics and Gynecology, Leeds Clinical Specialty Adviser (NPSA)

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Safety First Safety First highlights enter territories for development in current wellbeing reporting frameworks in the NHS. These include: Simplifying and empowering reporting More fast reporting Capturing hazardous circumstances Using tolerant wellbeing information to advise learning and activity locally investigation, learning and input

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Safer Practice in Intrapartum Care (SPIPC) Working with the NRLS (National Reporting and Learning System) Improving/institutionalizing occurrence reporting Develop obstetric care "groups" Implementing and testing Improving and Standardizing preparing Setting up frameworks of usage and assessment Standard information gathering

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"First, Do No Harm" Most specialists are minding people Highly gifted Highly prepared We all buckle down for the benefit of all No opportunity to report No opportunity to go to survey gatherings Beavering without end

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Problems for the Beaver To occupied with beavering endlessly to notice issues Coping with administration Learning closes with the mischance No review trail of issues or close miss request No "framework" memory No proposals/rule advancement No ability penetrates The framework is innately perilous Continued mishaps

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Improving Reporting Working with the NRLS Improving identification of patterns Highlighting bunches Looking at the great and in addition the terrible Improved cross examination of NRLS information Coding/trigger records Develop coordinate access for RCOG and RCM Share the higher need episodes Across all maternity administrations Gain quick criticism Instigate cautions/intercessions Provide more extensive learning for the NPSA

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Incident investigation Link with the SHAs Correlate CEMACH information Encourage SUI Improve security culture Encourage nearby investigation Standard SUI/RCA examination Allow total RCA Increase data accessible to focal offices

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Solution "We can't change the human condition, however we can change the conditions under which people work" James Reasons

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NICE rules

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Safer Practice in Intra-partum Care Find answers for all issues Not reexamine the wheel! Use what is out there Developing two obstetric "care packages" A "care bundle" is a gathering of intercessions identified with an infection procedure when executed together they result in preferred results over when actualized separately They should be held fast to and closed down

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Safer Practice in Intra-partum Care Obstetric "care groups" Aimed at enhancing tolerant wellbeing in intrapartum mind Placenta Previa in Previous Cesarean Section Intrapartum CTG appraisal Look for pilot/advancement destinations (10) sharp and less sharp locales, of all shapes and sizes Develop usage toolboxs Develop assessment tool compartments One-two year time scale Follow on from that point (RCOG/RCM purchase in)

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PP in Prev CS mind package - why? Generally uncommon occasion Associated with around half of Hysterectomies Incidence around 1/30 Associated with a large portion of the maternal passings from drain Incidence around 1/300 Problems identified with absence of readiness Awareness

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PP/CS mind package Where to begin? Direction for finding – CEMACH Bundle begins after determination Where to stop? Begin of methodology How can it fit into the entirety? Prove/rules/different packs What else is required? Usage/preparing

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EFM mind package - why? Obstetric cases represent more than 70% of all NHS case costs with a normal cost of cerebral paralysis instances of £1.5m. Current gauge that obstetric cases add up to £400m of aggregate £600m anticipated NHS costs. More than 85% of CP cases are connected with irregularities of fetal heart observing. Source: Learning from case: an investigation of cases for clinical carelessness – Vincent, Davy, Esmail, Neale, Elstein, Cozens, Walshe – August 2004

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EFM mind package Where to begin? Choice to utilize Labeling of lady Where to stop? After EFM evaluation How can it fit into the entirety? Prove/rules/different groups What else is required? Execution/preparing

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The IHI has perceives that: Sound science is known Application untrustworthy Evidence-based rules exist The test is to guarantee application

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Reasons for Evidence Committee What confirmation can be utilized? Best proof Believable Acceptable Pragmatic Ranking of confirmation We have to create finish package All segments secured with some confirmation!

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The Simulation and Fire bore Evaluation (SaFE) Learning focuses multiprofessional preparing bundles executed both locally and halfway for the most part generally welcomed by medicinal services staff Benefits of nearby preparing Work with neighborhood conventions and hardware. More financially savvy Helps clinical staff to re-take care of overhaul

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Audit execution and result Audit PP/CS package evaluation Has the package been taken after? Have the arrangements laid out been taken after? In the event that either were not, why not Outcome appraisal Audit of hysterectomy Audit of blood misfortune Admission to ICU Maternal Death

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We all need to assume liability to gain from our missteps and execute changes to attempt and stop them happening again … ..

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Setting principles to enhance ladies' wellbeing Royal College of Obstetricians and Gynecologists Risk Management and Medico-Legal Issues In Women's Health Joint RCOG/ENTER Meeting Please kill every cell phone and pagers