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Chapter 45 - Risk Management

Emergency Obstetric and Intrapartum Care

from Section 9 - Setting-Up Skills and Drills Training in Maternity Services and Reducing Avoidable Harm

Published online by Cambridge University Press:  06 May 2021

Edwin Chandraharan
Affiliation:
St George's University of London
Sir Sabaratnam Arulkumaran
Affiliation:
St George's University of London
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Summary

Risk management is a systematic approach to reducing the risk of harm to a patient. The concept of patient safety is not new; it has always been the goal of the clinician to achieve the best outcome for their patients. However, the formal process of risk management is a new and rapidly evolving aspect of healthcare. A key publication by the department of Health in the United Kingdom in 2000 highlighted the need to learn from clinical errors [1]. Therefore, recommendations were made for a new system of national reporting and analysis of adverse healthcare events bringing risk management to the fore. With this drive came documents for the royal colleges spelling out the need for robust risk management to ensure high quality care [2, 3].

Type
Chapter
Information
Obstetric and Intrapartum Emergencies
A Practical Guide to Management
, pp. 320 - 326
Publisher: Cambridge University Press
Print publication year: 2021

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References

Department of Health. An organisation with a memory: Report of an Expert Advisory Group on learning from Adverse Events in the NHS. London: The Stationary Office; 2000.Google Scholar
Royal College of Obstetricians and Gynaecologists, Royal College of Anaesthetists, Royal College of Midwives and Royal College of Paediatrics and Child Health. Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour. London: RCOG Press; 2007.Google Scholar
Royal College of Anaesthetists, Royal College of Midwives, Royal College of Obstetricians and Gynaecologists, Royal College of Paediatrics and Child Health. Standards for Maternity Care. Report of a Working Party. London: RCOG Press; 2008.Google Scholar
NHS Litigation Authority. Annual Report and Accounts 2017/18. NHS Resolution. https://resolution.nhs.uk/wp-content/uploads/2018/08/NHS-Resolution-Annual-Report-2017-2018.pdfGoogle Scholar
NHS Resolution. Five years of cerebral palsy claims. A thematic review of NHS resolution data. September 2017. https://resolution.nhs.uk/wp-content/uploads/2017/09/Five-years-of-cerebral-palsy-claims_A-thematic-review-of-NHS-Resolution-data.pdfGoogle Scholar
Neilson, PE, Goldman, MB, Mann, S, et al. Effects of teamwork training on adverse outcomes and process of care in labour and delivery: a randomised control trial. Obstet Gynecol. 2007;109:4855.Google Scholar
Schofield, H. Embedding quality improvement and patient safety at Liverpool Women’s NHS Foundation Trust. Best Pract Res Clin Obstet Gynaecol. 2007; 21(4):593607.Google Scholar
Royal College of Obstetricians and Gynaecologists. Improving Patient Safety: Risk Management for Maternity and Gynaecology. Clinical Governance Advice No. 2. London: RCOG; 2009.Google Scholar
Draper, ES, Gallimore, ID, Kurinczuk, JJ, Smith, PW, Boby, T, Smith, LK, Manktelow, BN, on behalf of the MBRRACE-UK Collaboration. MBRRACE-UK Perinatal Mortality Surveillance Report, UK Perinatal Deaths for Births from January to December 2016. Leicester: The Infant Mortality and Morbidity Studies, Department of Health Sciences, University of Leicester. 2018.Google Scholar
Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, National Patient Safety Agency. Safer Practice in Intrapartum Care Project Care Bundles. London: RCOG Press; 2010.Google Scholar
Chandraharan, E, Arulkumaran, S. Serious untoward incident. Obstet Gynaecol Reprod Med. 2007;17(5):163–4.CrossRefGoogle Scholar
Peerally, MF, Carr, S, Waring, J, Dixon-Woods, M. The problem with root cause analysis. BMJ Qual Saf. 2016;0:16.Google Scholar
ACT Academy of NHS Improvement. Root cause analysis using five whys. https://improvement.nhs.uk/resources/root-cause-analysis-using-five-whys/Google Scholar
Royal College of Obstetricians and Gynaecologists. Maternity Dashboard: Clinical Performance and Governance Scorecard. Good Practice No. 7. London: RCOG; 2008.Google Scholar
Chandraharan, E, Arulkumaran, S. The role of clinical dashboards in improving patient care: experience with the ‘Maternity Dashboard’. Ceylon Med J. 2016;61(2):83–5.CrossRefGoogle ScholarPubMed
Chandraharan, E, Arulkumaran, S. Clinical governance. Obstet Gynaecol Reprod Med. 2007;17(7):222–4.CrossRefGoogle Scholar

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