Professionals’ views about safety in maternity services.
This is an extract from a report on healthcare professionals’ views about safety in maternity services, published in 2008. The report identifies, along with various staffing and management issues, that learning lessons from mistakes and near-misses is one of the key problems in maternity.
Learning from adverse incidents is one of the key components of patient safety. There are numerous initiatives that seek to reduce incidents that impact on patient safety and ensure that lessons are learned from them. These include the Clinical Negligence Scheme for Trusts (CNST), the National Patient Safety Agency’s (NPSA) National Reporting and Learning System (NRLS), and Healthcare Commission investigations. A number of respondents emphasised the importance of learning from incidents as a key way of improving safety. Some had suggestions as to how such learning can most effectively be implemented. One respondent thought it critical that:
“[We] ensure we all learn from any adverse event or near miss in a constructive and non-judgemental way.”
(Consultant obstetrician, more than 11 years’ experience)
Others felt that regular multidisciplinary meetings and a ‘no blame’ system of reporting and analysing incidents were vital.
Some respondents were disillusioned and did not see the benefits of reporting incidents. They felt that unless a serious incident occurred, safety issues were not addressed.
“We fill in loads of incident forms but never see any actions from them.”
(Midwife, more than 11 years’ experience)
“A general opinion from midwives is: ‘It’ll take a critical incident before any changes take place.’ Why wait until then? Why subject a family and the staff involved to tragedy, when it could be prevented sooner? ”
(Midwife, 1-3 years’ experience)
“Safety depends on awareness of risk. Despite all the agencies available to reduce risk, ie, CNST, Patient Safety Agency, nothing happens till we have another Northwick Park incident [where 10 maternal deaths occurred in one unit in three years].”
(Consultant obstetrician and gynaecologist, more than 11 years’ experience)
Other respondents recognised that in order to build professionals’ confidence in the reporting system, feedback needed to be given and they needed to see evidence that action was being taken.
“By ensuring that safe codes/incident forms reporting are actioned and regularly fed back to units so that a belief in reporting unsafe situations that will result in solid action and change for the better is instilled and becomes something that midwives can have confidence in.”
(Midwife, 1-3 years’ experience)
“I think that the process of audit has to be more than a paper exercise and that the findings should be regularly incorporated to perinatal mortality/morbidity meetings, which includes the things we do well as well as those things we need to improve upon.”
(Midwife, more than 11 years’ experience)
“‘Safer’ can (quite wrongly) mean, to some, substituting bureaucracy and triple checking, rather than having inherently safe systems.”
(Obstetrician, more than 11 years’ experience)
The full report is available here at The Kings Fund, Inquiry into the safety of maternity services.
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