| | Risk management and medicolegal issues related to postpartum haemorrhage published online 28 August 2008. Postpartum haemorrhage (PPH) is a major cause of maternal mortality and morbidity. Despite several local and national guidelines and recommendations, the incidence of major obstetric haemorrhage has not declined significantly over the years. A high proportion of these cases involve patient safety incidents. The major themes in such incidents are: delay in diagnosis, failure to adhere to protocols, lack of consultant supervision, communication and documentation problems, inefficient teamwork and organizational failure. This chapter deals with ways of identifying the major contributory factors for adverse events associated with PPH and suggests solutions to minimize errors. Introduction  Reducing maternal mortality and morbidity is an essential component of safer childbirth in the twenty-first century. Although maternal mortality in developed countries is low (13.9/100,000 maternities in UK), postpartum haemorrhage (PPH) is one of the commonest causes of mortality and morbidity.1 Despite several audits, guidelines and recommendations for its management the incidence of PPH has not reduced significantly over the years. A culture of safety in maternity units, with risk management central to this, is extremely important in dealing with this problem, which accounts for thousands of maternal deaths worldwide. Safety should be everybody's business and the responsibility of each and every member of the maternity team.2 According to the latest Confidential Enquiries into Maternal and Child Health (CEMACH) report, 17 women died in the UK as a result of haemorrhage between 2003 and 2005, giving an incidence of 0.66 per 100,000 maternities.1 Of these maternal deaths, 59% of the women were found to have received major substandard care during the management of obstetric haemorrhage. A British study by Vincent, in 2001, highlighted that 10.8% of hospital patients in the UK suffer an adverse event.3 Half of these are preventable and a third lead to moderate or greater disability or death. The adverse event rate in obstetrics was 4.0%, with 71% of events being preventable. Massive PPH and peripartum hysterectomy are ‘near-miss’ events for maternal mortality. Study of such events greatly improves our knowledge of the risk factors and management associated with massive obstetric haemorrhage and also identifies the means of prevention. A recently published Scottish Confidential Audit of Severe Maternal Morbidity had a incidence of major obstetric haemorrhage of 3.7 per 1000 births.4 Since the commencement of annual maternal morbidity audits by Scottish Programme for Clinical Effectiveness in Reproductive Health (SPCERH) in 2003, major obstetric haemorrhage has remained the most common cause of severe maternal morbidity.5, 6, 7, 8 The quality of care these women received was noted to be suboptimal in 31–40% of cases. However, the majority of cases received incidental or minor substandard care (different care might have made a difference) and only 3% of women received major substandard care (i.e. management that contributed significantly to the morbidity; different management might have been expected to result in a more favourable outcome). This could reflect the impact that regular audits and learning from adverse events have on the quality of care. Data from the UK Obstetric Surveillance System (UKOSS) describe the reported causes, management and outcome of peripartum hysterectomy and associated haemorrhage in the UK.9 For each woman who dies in the UK following peripartum hysterectomy, more than 150 survive. However, obstetric haemorrhage is managed in a variety of ways, which might not be according to the existing guidelines. Postpartum haemorrhage can be avoided by prophylaxis and responds to simple measures in the majority of cases. The recurring theme of substandard care in most studies highlights the need to identify the reasons, contributory factors and learning points in cases of massive obstetric haemorrhage and develop an action plan locally and nationally. The following paragraphs focus on these points and deal with risk management in PPH. Major themes in risk management of adverse clinical events Several authors, including Brace et al4, and Neale et al10, have identified certain recurring themes in the risk assessment of adverse events. These include: misdiagnosis or delay in diagnosis, failure to adhere to protocols, lack of communication, inadequate senior input, underestimating the speed and extent of haemorrhage, poor documentation and systems failure. Adverse events usually occur as a result of a combination of factors occurring at the same time. In the Scottish audit, the most common contributing factor was ‘patient related’ (38%) followed by an ‘individual staff’ factor in 9% of cases. About 10% of women had more than one contributing factor identified. These factors are considered below, with suggestions about how they can be dealt with to reduce patient safety incidences in relation to PPH. Patient-related factors It is imperative to identify patients at risk of PPH.11 Apart from the well-known risk factors of antepartum haemorrhage, multiparity and obesity; women with a previous caesarean section have a higher incidence of morbid adherence of the placenta and subsequent haemorrhage.12, 13 Underlying medical problems, such as existing coagulopathy or sepsis leading to disseminated intravascular coagulation, should also be taken into account when stratifying women into risk categories. Ethnicity, social deprivation and language barriers have also been highlighted as potential risk factors for obstetric haemorrhage in several reports.*1, 14 Women declining blood and blood products (Jehovah's Witnesses) come into a very high-risk category due to their religious beliefs. Individual staff factors These lead to problems of misdiagnosis or a delay in diagnosis, inappropriate management, failure to adhere to protocols, acting beyond level of competence and failure to involve senior staff early. Most of these problems stem from a common theme: inadequate training or supervision. They might result from an inability to attend mandatory training sessions due to staffing problems or lack of funds for training. Other causes might be social, personal or psychological problems affecting the judgement and actions of an individual. Protocols and guidelines Failure to follow departmental protocols can result from several reasons, the most common being that staff are unaware of the protocols. It might also result from a lack of guidelines or the need for updating the existing guidelines or protocols.14 Staff members need proper training on the guidelines to avoid serious failures. Sometimes the guidelines might be too lengthy or repetitive. Ideally, they should be distilled into shorter, one- to two-page protocols, which should be readily available to the maternity staff, preferably in each delivery room. Guidelines and protocols are of no value unless they are implemented and audited regularly. Communication Poor communication and subsequent ineffective teamwork have been highlighted as major causes of mishaps in obstetrics.*2, *4 Communication between members of the same specialty, as well as between members of other relevant disciplines, including anaesthesia, haematology, radiology, intensive care and surgery, is essential for the appropriate management of a critically ill patient. Inadequate use of oxytocics Simple drugs like ergometrine and syntocinon are effective treatments for uterine atony.15, 16, 17 Despite this well-known fact, a number of women do not receive this basic uterotonic therapy.1 Ergometrine seems to be forgotten as an effective drug to control haemorrhage and the recommended therapeutic hierarchy is often ignored. The UKOSS report on peripartum hysterectomy found that one in ten women did not receive any treatment for haemorrhage other than hysterectomy.9 Delay in blood transfusion A healthy pregnant woman can lose up to 35% of her circulating blood volume (1200–1500 mL) before showing any signs of hypovolaemia. Inexperienced professionals managing massive obstetric haemorrhage often forget this fact, and do not start blood transfusion until it is too late. An additional factor might be underestimation of the blood loss, especially hidden loss, for example under the drapes at caesarean section or in a slow, steady trickle. Ignoring the results of basic monitoring Failure to recognize the early signs of haemorrhage, especially intra-abdominal bleeding after caesarean section, is increasingly being recognized as an issue. The recent CEMACH report highlighted this problem, commenting that ‘too little’ is done ‘too late’. Part of the problem might stem from a shorter postgraduate training period for junior doctors and a subsequent generation of consultants with insufficient experience in dealing with such emergencies. Documentation Poor or insufficient documentation is a major problem. In an unpublished audit of management of massive PPH at Liverpool Women's Hospital, conducted in 2007, the main reason for a decrease in adherence to the protocol was inconsistent documentation of events (S. Quenby, 2007, personal communication). The aspects that were particularly highlighted as being inconsistent were: documentation of the grades of the doctors attending, the record of maternal observations, the record of the management of the third stage of labour and the record of the number and gauge of intravenous cannulae used for resuscitation. Obstetrics is the highest risk specialty for medicolegal claims and subsequent monetary settlements. NHS Trusts risk-management teams and legal advisors are all too familiar with cases in which the Trusts have lost on account of poor documentation despite providing appropriate clinical care. Systems failure These can include deficiencies in the organization, lack of staff, faulty or outdated equipment, lack of resources, latent organizational factors and environmental factors. Studies looking into systems failure and latent organizational pitfalls in surgical specialities*18, 19 found the following factors to be common in adverse events: ineffective team work; coordination and communication problems; equipment problems; a relaxed safety culture; patient-related problems; skill, knowledge and decision-making failures. Non-technical errors were more common than technical errors and task threats were the most prevalent systemic source of error. The conclusion was that small problems, if not nipped in the bud, could escalate to serious proportions and lead to disasters. Solutions Albert Einstein once remarked that ‘things should be made as simple as possible, but not any simpler’. Human beings are fallible and errors are to be expected. It is vital to focus on the factors that influence error and conditions of work and minimize them. We must move away from individual blame culture and concentrate on methods to improve safety and prevention of such adverse events in future. High-reliability organizations such as the aviation industry provide the best examples of risk management.20 As aircraft accidents incur massive damages, including the loss of many lives; aviation has developed standardized methods of investigation, documentation and dissemination of errors and their lessons. Although delivery suites are not cockpits, obstetricians could learn a lot from the safety achievements of aviation. Identifying the problem and gathering information A key factor in finding solutions is obtaining as much information as possible about patient safety incidents. This can be in the form of local, national or regional audits, such as CEMACH and the Scottish audit on major obstetric haemorrhage. It might also be in the form of surveys about the attitude and behaviour of medical personnel in routine and emergency situations.20 Another important data source consists of non-punitive incident reporting system for adverse clinical events (ACE) reports. Individuals are encouraged to report any ACE or near miss without fear of reprisal. These reports often inform corrective actions and review of departmental guidelines and protocols. The identifying information can be removed and the data can also be shared between different hospitals for benchmarking purposes. Other sources of information might be departmental policies and guidelines, staff rotas, computerized records and factual statements from the persons involved. Root cause analysis The technique of root cause analysis (RCA) helps to determine the underlying causes of a safety incident. It is a methodology that enables us to ask questions such as ‘What?’, ‘How?’ and ‘Why?’ The National Patient Safety Agency (NPSA) has developed an RCA tool kit.21 This web-based resource contains tools to help perform a structured investigation to identify the root cause of a problem and the factors that contributed to the safety incident.22 This is essential to improve delivery of care to the patient and minimize the re-occurrence of adverse events. Most accidents or incidents fall into two groups: 1.Care delivery problems (CDP); 2.Service delivery problems (SDP). Care delivery problems arise during the delivery of care to the patient. This might be due to actions or omissions by members of staff (active failure) or lack of proper guidance (latent failure). Some examples include failure to act on results of monitoring and not seeking help when necessary. Service delivery problems are not associated with direct provision of care but with those decisions, procedures and systems that are part of service delivery. Examples include equipment failure, lack of staff and failure to undertake environmental risk assessment by the management. The contributory factors have been classified into nine categories by the NPSA framework (Table 1). | | |  | Contributory factor | Example | |
|---|
| 1. Patient | Language barrier | | | 2. Individual | Lack of clinical skills | | | 3. Task | Guidelines and policies | | | 4. Communications | Verbal or written | | | 5. Team and social | Team spirit and leadership | | | 6. Education and training | Supervision and availability | | | 7. Equipment and resources | Integrity and usability of equipment | | | 8. Working conditions | Administration and staffing | | | 9. Organisational and strategic | Safety culture and priorities | | | | |
Identification and analysis of potential contributory factors helps one to think laterally and beyond the immediate problem without missing relevant areas that might have affected the course of events. Some of the tools that can be used are outlined below. Brainstorming This method is used to generate as many ideas as possible around a topic. It is useful in identifying the various problems and possible contributory factors. It is also helpful in generating error reduction strategies and recommendations. Fishbone diagram Details about this graphical form of representing the various contributory factors resulting in a care or service delivery problem (Figure 1) are available from the NPSA website.21 In Reason's well-known Swiss cheese model of error23, the amalgamation of several factors, as shown in the fishbone diagram, leads to an adverse event as compared to a single factor. Other authors have corroborated these findings.24, 25 The five why's The main purpose of this popular tool is constantly to ask ‘why’ through various layers of the cause, and thus to progress towards the actual problem or the ‘root cause’. An example is shown in Figure 2. Barrier analysis This is another important tool for reaching the root cause of a problem.21 It helps in identifying when, how and why a defence mechanism erected to prevent a safety incident failed. It can also be used proactively to design effective barriers and control systems to provide a ‘fail-safe’ solution to the problem. Some examples of barriers commonly used in medical practice are locked cupboards to keep controlled drugs, dual checks before administering any controlled drug, and departmental protocols and procedures. However, barriers can sometimes create problems, for example, essential drugs for PPH might be locked away and the keys might not available when needed during emergency. It is crucial to understand why things go wrong if improvements are to be made in healthcare delivery to the patients. RCA helps in identifying the true cause of any problem and provides the foundation for subsequent recommendations to prevent such incidents from happening in future. Audits such as the CMACH, the Scottish audits of major obstetric haemorrhage and the UKOSS data on peripartum hysterectomy can be considered as part of a ‘mega’ RCA method looking into causes, learning points and recommendations in relation to PPH. The following sections deal with the proposed solutions and recommendations to prevent adverse events and near misses from repeating themselves, with special reference to PPH. Being proactive for the very high-risk woman A detailed antenatal management plan should be written in both the handheld notes and hospital notes of women at increased risk of PPH. Every woman who has had a previous caesarean section must have her placental site determined and morbid adhesions of the placenta excluded by judicious use of ultrasound and magnetic resonance imaging.1 There should be planned involvement of other specialities including haematology, radiology, general surgery, urology and medicine in known high-risk cases like suspected placenta accreta or percreta. Women declining blood transfusion The consultant obstetrician should see the woman antenatally along with her partner, family members and religious advisor if needed. A clear management plan should be documented in the notes in conjunction with the consultant anaesthetist. Informed consent should be taken for red-cell salvage and infusion during surgery; this facility should be provided for all such women. Women who decline blood transfusion should be seen by consultant obstetrician and anaesthetist in labour and a final management plan should be made. Any operative delivery or caesarean section should be performed under direct supervision of the consultant obstetrician and anaesthetist. Guidelines for the management of these women should be made available to and discussed with all maternity staff as part of their routine training, postgraduate education and continuous professional development and practice.1 Do not leave hysterectomy too late Hysterectomy should be undertaken sooner rather than later as earlier hysterectomy results in lower blood loss and possibly reduced additional morbidity.9 Subtotal hysterectomy is preferable in presence of massive bleeding due to the speed of operation.26 In the event of major obstetric haemorrhage, especially if hysterectomy is needed, it is a good practice to call for help early from colleagues with greater gynaecological experience; this should not be seen as ‘losing face’.1 Appropriate use of oxytocics Use of prophylactic oxytocin infusion postpartum in high-risk women is important, and ergometrine should not be forgotten in the therapeutic hierarchy–it is very effective and much cheaper than second-line drugs like prostaglandin F2α and recombinant factor VIIa. Misoprostol is a particularly useful alternative in underdeveloped countries because it is cheap, does not require refrigeration and does not need to be given by injection. Educating the women to recognize early signs of haemorrhage According to WHO estimates, some 140,000 deaths per year could be prevented globally if only women were educated about the possible warning signs of bleeding, knew when to seek help and had access to emergency obstetric services.27 The situation in developed countries is far better than in low-income countries, but it is still important to teach women to recognize signs of ‘trickling’ PPH. If it is not appropriately dealt with in time, the cumulative blood loss can result in collapse of a supposedly ‘low-risk’ woman in low-dependency areas like the midwifery-led units and postnatal wards. A simple solution has been developed at Liverpool Women's NHS Foundation Trust to improve recognition of trickling PPH. A poster displayed in patient bathrooms shows what is normal and what is heavy loss. It includes instructions for women to notify their midwife if loss is excessive (Figure 3). Since this poster has been displayed, there has been a huge reduction in delayed diagnosis of ‘trickling PPH’. Another way to deal with this problem is to institute safety barriers like mandatory 3- to 4-hour postnatal checks in midwife-led units, with the midwife documenting the findings in the patient's notes. Proper estimation of blood loss A visual estimate of blood loss correlates poorly with the actual loss, especially at extremes of measured blood loss (MBL).28 Bose et al assessed the accuracy of visual estimation of blood loss by reconstructing clinical scenarios using expired blood.29 Based on their findings, they devised a pictorial algorithm to be used as a teaching tool for labour wards to improve the visual estimation of blood loss and thereby facilitate timely resuscitation and minimizing the severity of haemorrhagic shock. Reducing delays and improving problems with blood transfusion The following can help: •recognize the need for immediate blood transfusion; •use ‘emergency’ O-negative blood in life-threatening situations; •clear communication with haematology and transfusion services; •dedicated courier service to take samples and bring blood back; •an on-site technician; •automated issue system for blood; •blood warmers; •a cell salvage system; •avoiding ‘dilutional coagulopathy’ by early recourse to fresh frozen plasma (FFP) and other blood products; •equipment to quickly thaw large quantities of clotting factors. A useful method is to have a ‘levels of urgency’ system to order blood. For example, at Liverpool Women's Hospital there are three levels of urgency. Level 3 is a routine request for blood; level 2 is when blood is needed quickly–within 1 hour; and level 1 is a life-threatening situation when blood is needed immediately. This information is displayed at strategic areas on the labour ward, as well as near the telephones, so that everyone who informs the laboratory speaks the same language. Another suggestion is to have a dedicated ‘hot line’ between the delivery suite and haematology department, perhaps with a different-coloured telephone. This can reduce the time taken for communication by bypassing the switchboard. Early detection of signs of internal bleeding One of the three main lessons learned from the last CEMACH report is the identification and management of intra-abdominal bleeding, especially after caesarean section. The recognition of life-threatening bleeding in these situations can be challenging because of the physiological changes of pregnancy, which conceal the development of serious pathology. An Early Warning Score (EWS) is a simple physiological scoring system that can be performed at the patient's bedside using commonly used parameters in sick patients.30 These are also known as patient-at-risk scores (PARS) or modified early warning scores (MEWS). The five parameters that are usually used to calculate the score are: (1) mental response; (2) pulse rate; (3) systolic blood pressure; (4) respiratory rate; and (5) temperature. In postoperative patients, a sixth parameter–urine output–is also included. The principle is that smaller changes in all the parameters combined will be noticed earlier than a large change in one parameter alone. For example, marked drop in blood pressure is usually a late sign of hypovolaemia, whereas respiratory rate is one of the most sensitive marker of patient's well being. The MEWS scores need to be modified slightly for obstetric use to take into account the physiological changes of pregnancy: Modified Early Obstetric Warning Scoring system (MEOWS). Some units have devised their own MEOWS charts, for example the Aberdeen Maternity Hospital1 and Liverpool Women's Hospital (Figure 4). However, early detection of signs of bleeding is of no value unless action is taken. The flow chart in Figure 5 suggests a pathway for the management of abnormal MEOWS scores. Improving adherence to guidelines and protocols There should be a single set of evidence-based guidelines, which could be modified according to the local needs. Lengthy guidelines need to be summarized into easy-to-use, single-page protocols, which should be readily available. Staff should be trained in the use of guidelines and protocols and their implementation should be audited regularly. Rizvi et al found a significant reduction in the incidence of massive PPH after the revision of departmental guidelines and staff education.31 Regular audits also improve adherence to protocols and guidelines, thereby reducing the incidence of adverse events. Since the commencement of Scottish Confidential Audit of Severe Maternal Morbidity, there has been a steady decline in the rate of peripartum hysterectomy in Scotland: from 15% in 2003 to 8% in 2006.8 Several other errors have also declined over the years (Table 2). | | | | Problems or errors identified | 2003 | 2004 | 2005 | 2006 | |
|---|
| Avoidable delay in diagnosis/treatment | 16% | 14% | 9% | 8% | | | Failure to follow protocol/plan | 14% | 12% | 11% | 6% | | | Appropriate conclusion/differential not made | 9% | 3% | 2% | 6% | | | Poor communication | 3% | 6% | 5% | 5% | | | | |
Bundles A ‘bundle’ is a group of interventions related to a disease process that, executed together, result in better outcomes than when implemented individually. They must be adhered to. The Royal College of Obstetricians and Gynaecologists (RCOG) and National Patient Safety Agency (NPSA) are currently developing ‘bundles’ and processes of care for managing two specific high-risk maternity situations: cardiotocography (CTG) monitoring and placenta praevia following a previous caesarean section. The placenta praevia in previous caesarean section bundle includes a number of actions that must take place in the care of these women32, including: •consultant involvement in planning the delivery and presence at the time of surgery; •immediate access to blood and blood products; •multidisciplinary involvement; •consent issues including cell salvage, interventional radiology and hysterectomy; •the availability of a high-dependency bed for the postnatal period. This is to be piloted in six sites in the UK, and it is hoped that compliance with this bundle will improve outcomes for these very high-risk women following the success of bundles in other areas, notably the surviving sepsis campaign bundles.33, 34, 35 Another tool that can help in the integration and presentation of guidance is the ‘map of medicine’. This is a web-based visual representation of evidence-based patient care journeys covering 28 medical specialties and 307 care pathways, including term labour, caesarean section, intrapartum fetal monitoring and haemorrhage.36 Education and training The concept of adult learning or ‘andragogy’ is different from child learning or ‘pedagogy’.37 Adult learning is mainly ‘self-directed’ and ‘internally motivated’. Prior experience forms a rich resource for learning in adults. Learning by doing or ‘experiential learning’ is the cornerstone of adult learning in medicine. It is based on the notion that understanding or knowledge is not a fixed element of thought but is formed and reformed through ‘experience’.38 Experiential learning is therefore a continuous, cyclical process. This cyclical model of learning is also known as the ‘Kolb learning cycle’ (Figure 6).39 For successful learning to take place, four kinds of abilities or undertakings are required: 1.Concrete experience (CE): doing something new. 2.Reflective observation (RO): reflecting on the experience from different perspectives. 3.Abstract conceptualization (AC): thinking and processing one's ideas. 4.Active experimentation (AE): furthering understanding to make decisions and solve problems. All four stages of the process are necessary if effective learning to occur. It is important to consider the underpinning theories of adult learning and different styles of learners when any new education or training programme is designed. Training Training is defined as the systematic acquisition of knowledge (what we think), skills (what we do) and attitudes (what we feel), which lead to improved performance in a particular environment.40 This is the cognitive domain or the major area of learning in any discipline. The use of simulated training in medical education has increased enormously in recent years. It creates a safe environment for health professionals to learn and practice difficult skills without actually harming patients. It offers an opportunity to teach error management and safety culture in a risk-free environment and provides an improved method for demonstrating and documenting competence. The national obstetric emergency training courses like Advanced Life Support in Obstetrics (ALSO) and Managing Obstetric Emergencies and Trauma (MOET), as well as locally run courses, utilize the principle of simulation extensively. Simulation-based training has been shown to reduce errors and risks in obstetrics, and to improve team working and communication skills.41, 42 Draycott and Crofts have shown sustained improvement in neonatal outcome following the introduction of obstetric emergency training in Bristol.43 A similar outcome was noted at Liverpool Women's Hospital, when there was 50% reduction in the incidence of low cord pH after the introduction of training in 2001.44 Simulated scenarios also provide the perfect tool for the assessment of an individual's competency. These can range from assessing communication skills, manual dexterity, teamwork and managing information systems, to difficult and high-level skills like decision making in a crisis. Multidisciplinary Obstetric Simulated Emergency Scenarios (MOSES) training is an example.2 Crofts et al recently published a prospective randomized controlled trial as part of the Simulation and Fire drill Evaluation (SaFE) study.45 The aim of this study was to explore the effect of obstetric emergency training on knowledge, as well to assess if acquisition of knowledge is influenced by the training setting or teamwork training. It was concluded that practical, multiprofessional, obstetric emergency training increased midwives' and doctors' knowledge of obstetric emergency management, including PPH. Neither the location of training, in a simulation centre or in local hospitals, nor the inclusion of formal teamwork training made a significant difference to the acquisition of knowledge or team-working in obstetric emergencies. The results of the wider SaFE study are awaited. Training in the management of PPH and other obstetric emergencies should be mandatory for all clinical staff providing maternity care services. Regular ‘fire drills’ should also be organized to test the local system in real time. These help to identify problems in the system and generate solutions. Repeat drills should be performed to check the efficacy of solutions. Teams that work together should train together, ideally in their local environment. There is also a need for a nationally approved scenario-based team-training programme in the management of massive obstetric haemorrhage, involving not only the obstetric staff but also the anaesthetists, theatre, recovery and high-dependency teams. Improving communication skills and team working Effective communication is essential for safe clinical practice. It should not merely be a case of ‘transferring’ information from one source to another but should be properly understood by the person who needs to act upon it. All maternity units should have clear standards of communication. Staff should be encouraged to speak out about their concerns and worries, rather than protecting the hierarchy or position. In case of doubt, clinicians should be encouraged to ask for a second opinion or advice. An example of formal communication protocol is the SBAR (Situation–Background–Assessment–Recommendation) tool. This can be downloaded from the Institute for Healthcare Improvement website.46 It is an effective way of communicating between team members about a seriously ill patient. An example is shown in Figure 7. Team work The recent King's Fund enquiry ‘Safe Birth: Everybody's Business'47 highlights the importance of team working in maternity service. Effective team work improves organizational performance in terms of efficiency and quality. It enhances performance by reducing errors and improving the quality of patient care.48 Members of a team can create additional defences against error by monitoring, double-checking and backing each other up; when one is struggling, another assists; when one makes an error another recognizes and rectifies it.2 The following are necessary to improve the efficiency of teamwork: •a clear set of aims and objectives; •well-defined roles and responsibilities for team members; •effective leadership; •clear standards and protocols for communication; Improving documentation Documentation can be improved by using standard documentation guidelines, which include a chronological and accurate record of events in clear and legible handwriting. Each entry should be dated, timed and signed by the individual, who should record his or her name and grade at the end. In emergencies like massive obstetric haemorrhage, it is a good practice to have a ‘scribe’ who notes down the timing of each event. Use of documentation aids, for instance those used at South Tees Hospital, can be very helpful in improving documentation (Figure 8). Preventing systems failure An important aspect of preventing systems failure is to identify latent threats in the system that can interact with ongoing activities to precipitate error. The extent of latent threats can range from simple matters like malfunctioning on call bleeps to bigger issues like inadequate staffing levels and poor organizational structure. If these threats are recognized and corrected in time, a major adverse event can be prevented.49 An method of preventing equipment failure and improving outcomes is to set up a PPH trolley on the delivery suite housing all the necessary drugs and equipment. Another innovation could be to prepare a surgical tray with all the instruments and instruction sheets needed for complex surgical procedures to control PPH, like internal iliac artery ligation, hysterectomy, B Lynch sutures and balloon tamponade. Baskett et al found that the ready availability of an obstetric haemorrhage equipment tray on the labour ward facilitates prompt surgical management of severe obstetric haemorrhage, and could reduce the need for blood transfusion and hysterectomy.50Once again, effective teamwork is very important as it can identify latent deficiencies in the system and rectify them before they escalate into serious incidents. Conclusion PPH is a life-threatening situation, which fortunately responds to simple measures of treatment provided there is forward planning and anticipation. Every unit should have clear guidelines and protocols for the management of PPH and their implementation should be audited regularly. A robust risk management system should be in place to deal with any adverse events related to major obstetric haemorrhage. Error management should become an ongoing organizational commitment to building a healthy and safe environment for patients as well as the staff members. Only then can we truly provide a healthcare system fit for the twenty-first century. Practice points•Provide clear performance standards and review local protocols. •Adopt a non-punitive approach to error. •Identify and resolve interpersonal conflicts between team members. •Review resources and staffing levels. •Provide feedback to staff including positive points. •Disseminate learning points to wider staff via newsletters or meetings. Research agenda•The frequency of training updates in the management of obstetric emergencies such as PPH. •The impact of the NPSA care bundle for placenta praevia in women with previous caesarean section. •The impact of communication techniques such as SBAR and documentation aids. •Early warning scores in obstetrics. References *1. 1.In: Lewis G editors. Saving mothers' lives: reviewing maternal deaths to make motherhood safer 2003–2005. London: RCOG Press; 2007;. *2. 2.In: Walker I, Grise E editor. Safe Births: everybody's business. An independent inquiry into the safety of maternity services in England. King's Fund; 2008;. 3. 3Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals. BMJ. 2001;322:517–519. *4. 4.Brace V, Kernaghan D, Penney G. Learning from adverse clinical outcomes: major obstetric haemorrhage in Scotland, 2003–2005. BJOG. 2007;114:1388–1396.
CrossRef
5. 5Penney G, Brace V. Scottish confidential audit of severe maternal morbidity: first annual report. Scottish Programme for Clinical Effectiveness in Reproductive Health, Aberdeen, 2003. 6. 6Penney G, Adamson L, Kernaghan D. Confidential audit of severe maternal morbidity: second annual report. Scottish Programme for Clinical Effectiveness in Reproductive Health, Aberdeen, 2004. 7. 7Penney G, Kernaghan D, Adamson L. Confidential audit of severe maternal morbidity: third annual report. Scottish Programme for Clinical Effectiveness in Reproductive Health, Aberdeen, 2005. 8. 8Penney G, Adamson L. Confidential audit of severe maternal morbidity: fourth annual report. Scottish Programme for Clinical Effectiveness in Reproductive Health, Aberdeen, 2006. *9. 9.Knight M, on behalf of UKOSS . Peripartum hysterectomy in the UK: management and outcome of the associated haemorrhage. BJOG. 2007;114:1380–1387.
CrossRef
10. 10Neale G, Woloshyowych M, Vincent C. Exploring the causes of adverse events in NHS hospital practice. J R Soc Med. 2001;94:322–330. MEDLINE 11. 11Stones RW, Paterson CM, Saunders NJ. Risk factors for major obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol. 1993;48:15–18. MEDLINE |
CrossRef
12. 12Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: case-control study. BMJ. 2001;322:7294. 13. 13Taylor LK, Simpson JM, Roberts CL, et al. Risk of complications in a second pregnancy following caesarean section in the first pregnancy: a population-based study. Med J Aust. 2005;183(10):515–519. 14. 14Healthcare Commission . Investigation into 10 maternal deaths at, or following delivery at, Northwick Park Hospital, North West London Hospitals NHS Trust, between April 2002 and April 2005. London: Healthcare Commission; 2006; www.healthcarecommission.org.uk. 15. 15Moir JC. The action of ergot preparations on the postpartum uterus. Br Med J. 1932;1:520–523. MEDLINE 16. 16Winter C, Macfarlane A, Deneux-Tharaux C, et al. Variations in policies for management of the third stage of labour and the immediate management of postpartum haemorrhage in Europe. BJOG. 2007;114(7):845–854.
CrossRef
17. 17Moussa H, Alfirevic Z. Treatment for primary postpartum haemorrhage. Cochrane Database Syst Rev. 2007 Jan;. *18. 18.Catchpole KR, Giddings AE, Wilkinson M, et al. Improving patient safety by identifying latent failures in successful operations. Surgery. 2007;142(1):102–110. Abstract | Full Text |
Full-Text PDF (599 KB)
19. 19Catchpole KR, Giddings AE, de Leval MR, et al. Identification of systems failures in successful paediatric cardiac surgery. Ergonomics. 2006;49(5–6):567–588. MEDLINE |
CrossRef
*20. 20.Helmreich RL. On error management: lessons from aviation. BMJ. 2000;320:781–785. *21. 21.National patient safety agency. Root cause analysis tool kit. http://www.npsa.nhs.uk/patientsafety/improvingpatientsafety/patient-safety-tools-and-guidance/rootcauseanalysis/rcatoolkit/. 22. 22Ammerman M. The root cause analysis handbook: a simplified approach to identifying, correcting and reporting workplace errors. New York: Quality Resources; 1998;. *23. 23.Reason JT. Understanding adverse events: the human factor. In: Vincent C editors. Clinical risk management: enhancing patient safety. London: BMJ Publishing Group; 2001;p. 9–30. 24. 24Vincent C, Taylor-Adams SE, Chapman EJ, et al. How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. Br Med J. 2000;320:777–781. 25. 25Woolf SH, Kuzel AJ, Dovey SM, et al. A string of mistakes: the importance of cascade analysis in describing, counting and preventing medical errors. Ann Fam Med. 2004;2:317–326. MEDLINE |
CrossRef
26. 26Roopnarinesingh R, Fay L, McKenna P. A 27-year review of obstetric hysterectomy. J Obstet Gynaecol. 2003;23:252–254. MEDLINE |
CrossRef
27. 27Abou Zahr C. Global burden of maternal death. In: British Medical Bulletin editors. Pregnancy: reducing maternal death and disability. British council. Oxford University Press; 2003;. 28. 28Razvi K, Chua S, Arulkumaran S, et al. A comparison between visual estimation and laboratory determination of blood loss during the third stage of labour. Aust N Z J Obstet Gynaecol. 1996;36(2):152–154. MEDLINE |
CrossRef
29. 29Bose P, Regan F, Paterson-Brown S. Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions. BJOG. 2006;113(8):919–924. MEDLINE |
CrossRef
30. 30Clutton-Brock T. Critical care. In: Lewis G editors. Saving mothers' lives: reviewing maternal deaths to make motherhood safer 2003–2005. London: RCOG Press; 2007;p. 238–245. 31. 31Rizvi F, Mackey R, Barrett T, et al. Successful reduction of massive postpartum haemorrhage by use of guidelines and staff education. BJOG. 2004;111:495–498. MEDLINE |
CrossRef
32. 32RCOG/NPSA. Care bundle for women with previous Caesarean section at risk of a morbidly adherent placenta. London: RCOG, in press. 33. 33Dellinger RP, Carlet JM, Masur H, et al. Surviving sepsis campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004;32:858–873. MEDLINE |
CrossRef
34. 34Levy MM, Pronovost PJ, Dellinger RP, et al. Sepsis change bundles: converting guidelines into meaningful change in behaviour and clinical outcome. Crit Care Med. 2004;32:S595–S597. MEDLINE |
CrossRef
35. 35Gao F, Melody T, Daniels D, et al. The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study. Crit Care. 2005;9:R764–R770.
CrossRef
36. 36Map of medicine. http://healthguides.mapofmedicine.com2007;. 37. 37Knowles M. Andragogy in action. Houston, TX: Gulf Publishing Co; 1984;. 38. 38Fry H, Ketteridge S, Marshall S. Understanding student learning. In: A handbook for teaching and learning in higher education. London: Kogan Page; 2003;. 39. 39Kolb DA. Experiential learning. New Jersey: Prentice-Hall, Englewood Cliffs; 1984;. 40. 40Benjamin S, Bloom BBM, Krathwohl DR. Taxonomy of educational objectives. New York, NY: David McKay; 1964;. 41. 41Birch L, Jones N, Doyle PM, et al. Obstetric skills drills: evaluation of teaching methods. Nurse Educ Today. 2007;27(8):915–922. Abstract | Full Text |
Full-Text PDF (128 KB)
|
CrossRef
42. 42Maslovitz S, Barkai G, Lessing JB, et al. Recurrent obstetric management mistakes identified by simulation. Obstet Gynecol. 2007;109(6):1295–1300. MEDLINE 43. 43Draycott T, Crofts J. Structured team training in obstetrics and its impact on outcome. Fetal Matern Med Rev. 2006;17:229–237. *44. 44.Scholefield H. Embedding quality improvement and patient safety at Liverpool Women's NHS Foundation Trust. In: Best practice & research clinical obstetrics & gynaecology. vol. 21:2007;p. 593–607.
CrossRef
*45. 45.Crofts J, Ellis D, Draycott T, et al. Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomized controlled trial of local hospital, simulation center and teamwork training. BJOG. 2007;114:1534–1541. 46. 46Institute for healthcare improvement . SBAR technique for communication: a situational briefing model. http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm. 47. 47The Kings Fund . Safe births: everybody's business an independent inquiry into the safety of maternity services in England. London: Kings Fund; 2008;. 48. 48West MA, Borrill CS. The influence of team working. In: Cox J, King J, Hutchinson A, et al. editor. Understanding doctors' performance. Oxford: Radcliffe Publishing; 2005;. 49. 49Sexton JB, Thomas EJ, Helmreich RL. Error, stress and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000;320:745–749. 50. 50Baskett TF. Surgical management of severe obstetric haemorrhage: experience with an obstetric haemorrhage equipment tray. J Obstet Gynaecol Can. 2004;26(9):805–808. MEDLINE Consultant Obstetrician and Gynaecologist Lead Clinician for Risk Management Wrexham Maelor Hospital, Wrexham, UK Liverpool Women's NHS Foundation Trust, Liverpool, UK  Corresponding author: Tel.: +44 151 702 4013; Fax: +44 151 702 4255.
PII: S1521-6934(08)00104-1 doi:10.1016/j.bpobgyn.2008.08.007 © 2008 Published by Elsevier Inc. | |
|
FULL TEXT00104-1/journalimage?img=PIIS1521693408001041.gr1.lrg.gif&fig=fig1&kwhquery=&issn=1521-6934&ishighres=false&allhighres=false&free=yes','journalimage');)
00104-1/journalimage?img=PIIS1521693408001041.gr2.lrg.gif&fig=fig2&kwhquery=&issn=1521-6934&ishighres=false&allhighres=false&free=yes','journalimage');)
00104-1/journalimage?img=PIIS1521693408001041.gr3.lrg.gif&fig=fig3&kwhquery=&issn=1521-6934&ishighres=false&allhighres=false&free=yes','journalimage');)
00104-1/journalimage?img=PIIS1521693408001041.gr4.lrg.gif&fig=fig4&kwhquery=&issn=1521-6934&ishighres=false&allhighres=false&free=yes','journalimage');)
00104-1/journalimage?img=PIIS1521693408001041.gr5.lrg.gif&fig=fig5&kwhquery=&issn=1521-6934&ishighres=false&allhighres=false&free=yes','journalimage');)
00104-1/journalimage?img=PIIS1521693408001041.gr6.lrg.gif&fig=fig6&kwhquery=&issn=1521-6934&ishighres=false&allhighres=false&free=yes','journalimage');)
00104-1/journalimage?img=PIIS1521693408001041.gr7.lrg.gif&fig=fig7&kwhquery=&issn=1521-6934&ishighres=false&allhighres=false&free=yes','journalimage');)
00104-1/journalimage?img=PIIS1521693408001041.gr8a.lrg.gif&fig=fig8&kwhquery=&issn=1521-6934&ishighres=false&allhighres=false&free=yes','journalimage');)
00104-1/journalimage?img=PIIS1521693408001041.gr8b.lrg.gif&fig=fig8&kwhquery=&issn=1521-6934&ishighres=false&allhighres=false&free=yes','journalimage');)