Clinical risk management in labour

Amila Weerasinghe

&

Channa Gunasekara

of

Faculty of Medical Sciences,

University of Sri Jayewardenepura,

Sri Lanka.

2014/09/8

Definition• Clinical risk management can be defined as

organizational systems or processes that aimto improve the quality of health care andcreate and maintain safe systems of care..

• In obstetrics , it is particularly important as itis a high risk specialty and the cost ofmistakes is high, both financially and inhuman terms.

• AimTo improve standards of care andsubsequently reduce the harm occurring towoman and their babies.

So eventually, it should decrease number ofcomplains and the cost for litigations.

• Human error is inevitable, so there is a need to understand the theory of human error and the systems, rather than person-centred, approach to dealing with adverse events.

• ‘We cannot change the human condition, but we can change the conditions under which humans work.’Reason J. Managing the Risks of Organizational Accidents.

Aldershot: Ashgate; 1997.

Principles of risk management

The following need to be recognized when considering medical error:

• uncertainty of clinical practice;• nature of clinical decisions;• benefits of hindsight;• frequency of activity;• error-producing conditions under which we work;• fact that people do not intend to commit errors;• that accidents are rarely due to single errors but are

the product of multiple factors;• that the psychological precursors of error are the last

and least manageable stages in the accident chain.

Types of errors

• Slips and lapses

recognition: e.g. thecardiotocograph (CTG);

attention: interruptions and distractions from thetask;

memory: something is forgotten;

selection: the wrong medication is chosen from anumber of ampoules that look the same.

• Mistakes

Rule based: eg; syntometrine is given foractive management of the third stage in awoman with hypertension and shesubsequently has a fit. A good rule is used inthe wrong situation.

Knowledge based: There is not a knownpreplanned course of action. A plan is workedout to deal with this, but it does not have thedesired effect.

• Violation

Routine: cutting corners, e.g. not logging off thecomputer;

Reasoned: the only option in the circumstances,such as a trial of forceps for fetal bradycardia in thedelivery room as the theatre is busy;

Reckless: harm is foreseeable but not intended,

e.g. using multiple instruments in a trial ofinstrumental delivery;

Malicious: deliberately harmful: motivated by or resultingfrom a desire to cause harm or pain to another.

eg: such as the recently publicized case of the GPHarold Shipman.

Plight of Sri Lanka

• Though there are general rules and bylaws introduced by certain authorities;

Such as SLMC , Ministry of health , civil law…. Etc

There isn’t a proper clinical risk management program conducted by any responsible authority.

What are the components should be there to establish an effective clinical

risk management in labour ?

• Organizational culture

• Learning from adverse incidents

Liam Donaldson, Chief Medical Officer, has said in relation to this that ‘To err is Human. To cover up is unforgivable. To fail to learn is inexcusable.

• Medical and midwifery staff

are encouraged to report when

things go wrong.

1. Antenatal clinics

2. On the delivery suite

3. On the obstetric wards

• Risk assesment

Aims to identify risks before adverse events occureand put into place procedures, barriers and other measures to reduce these risks.

Personnel: staffing levels, skill mix and training;

Estate: a safe environment for staff and patients;

Equipment: CTG machines, infusion pumps, etc.;

Practice: policies and procedures.

•Training, induction and competence

Inexperience increases the risk of error four-fold,so training is extremely important in risk management.

eg :- CTGs - formal teaching sessions, CTG review meetings and electronic training packages.

• Resuscitation- Both adult and neonate. all

maternity staff know how to deal with collapse

while awaiting the arrival of the crash team.

• Drills - for shoulder dystocia,vaginal breech delivery, cord prolapse, eclampsia and massive haemorrhage.

• Equipment - Matrices are useful in identifying which members of staff need training on particular items of equipment; those who are

not trained must not use them.

• Supervised practice - This allows staff to develop their skills and allows competencies to be assessed while minimising the risk to patients.

•Guidelines

• Greentop / RCOG

• Nice

• SLCOG

•Communication

Communication with the patient

• Consent should be taken adequately for procedures.

• Patients must be given enough information about the procedure and its risks, benefits and alternatives to make an informed decision about it.

• Patients who are mentally competent have the right to refuse treatment even if that might result in harm to themselves or the death of their baby.

Communication between professionals

• This needs to encompass communication between the hospital services and community and primary care.

• All the relevant professionals must be kept informed of the plan of care and any complications.

• Adequate discharge information is essential.

• Documentation must be legible, dated and signed. It should include the discussions that have taken place with the patient and a management plan, and key individuals should be identified.

•Audit

Audit of labour ward outcomes can detect if guidelines are not being followed or certain standards are not being met.

Repeat audit should show improvements occurred due to actions taken.

Resources for reducing the risk on labour wards

• National Patient Safety Agency [www.npsa.nhs.uk] Excellent site with good resources on patient safety including e-learning modules on patient safety and root cause analysis.

• NHS Litigation Authority [www.nhsla.com] Facts and figures on claims for negligent harm.

• Medical Devices Agency [www.medical-devices.gov.uk] Provides updates and alerts for medical devices. Also gives articles and reviews about specific risks, e.g. infusion devices.

• World Health Organization [www.who.int/patientsafety/en] Setting the international agenda for patient safety.

• Institute for Safe Medication Practices: Canada [www.ismpcanada.org] Resources include safety publications including alerts and bulletins, surveys, andinformation on the Canadian Medication Incident Reporting and Prevention System (CMIRPS).

• Australian Council for Safety & Quality in Health Care [www.safetyandquality.org] This site provides an overview of the patient safety agenda in Australia, including news reports, publications, resources, events and areas for action in patient safety.

• American College of Obstetricians and Gynecologists [www.acog.org/from_home/departments/dept_notice. cfm?recno=28&bulletin=2491] American College website on quality and patient safety with a series on patient safety tips.

• National Patient Safety Foundation [www.npsf.org] Access to US sites on patient safety. Excellent resources for involving patients in safety.