Sharing your safety concerns
By Karen Hooper on 23 November 2018 Midwives Magazine
Karen Hooper offers insights into the National Reporting and Learning System by looking at safety incidents during three everyday maternity practices.
Learning from incidents is key to improving patient safety across the NHS. Healthcare staff are encouraged to report safety incidents, including where no harm has occurred – or ‘near-miss’ events – to identify new risks, share learning from care episodes and to improve the overall safety of patients.
Trust incident management systems in England and Wales feed all reports into the National Reporting and Learning System (NRLS). Apparently isolated or rare occurrences in one unit can be scaled up by reviewing all similar incidents reported nationally to identify opportunities for broader learning and sharing of best practice.
Emphasising the value of incident reporting both to clinicians and the general public can be challenging – especially when discussing actual numbers of incidents reported.
Supporting a safety culture
The number of reports submitted to the NRLS should not be used as a direct measure of patient safety. First, reporting is voluntary; second, the number is the converse of what might be expected: an increase in patient safety incident reports demonstrates a healthy safety culture where staff feel empowered and encouraged to talk openly and improve learning. The only way to learn from patient safety incidents is to talk about them.
We are able to support learning across the system in various ways, including issuing patient safety alerts and working with royal colleges, voluntary services and other relevant teams to influence guidance, support patients and families with information, and share learning. Disseminating information to the appropriate staff can be challenging, so this article will describe a number of recent reviews relevant to the everyday practice of healthcare staff working with pregnant women, mothers and their babies.
1 . Unintended injury when cutting the umbilical cord at birth
The NRLS received 18 reports over a two-year period of harm through accidental cuts to babies when birthing partners were involved in cutting the umbilical cord. Most of the incidents reported low levels of harm; however, in two reports, toes were partially amputated, requiring treatment including transfer/surgery.
Many birthing partners choose to cut the cord following the birth of the baby to enable them to be further involved in the birthing process. Healthcare professionals are in a unique position to support their wishes in a safe way by providing instruction and observation to reinforce careful positioning of the baby.
2. Bursting birthing balls
Physiotherapy balls were developed in the 1960s for use as part of a physio rehabilitation programme. Similar balls are now in wide antenatal use to relieve back discomfort, maintain fitness during pregnancy and encourage optimal fetal positioning. They are often used during labour for comfort, to encourage progression of labour and to maintain an active labour.
The NRLS received 76 reports of birthing balls bursting while in use in a maternity setting. In addition, there were another 25 reports of balls bursting while being used in other settings, such as physio or rehab.
In most of the incidents there was little or no harm following the fall, with women being supported back to their feet by midwives or birthing partners. On three occasions there were associated injuries, including lower back pain, spontaneous rupture of membranes and a dislodged cannula.
Following the incidents, care generally involved assessment of fetal wellbeing, cardiotocograph (CTG) and fetal movements, and observation for physical injury to the mother.
Many units provide birthing balls, and many women have their own for use at home.
Those specifically marketed as birthing balls claim to support weights of up to 300kg, can be inflated to different diameters dependent on maternal height and are marketed as ‘anti-burst’.
Maternity units should consider purchasing good-quality birthing balls, ensuring regular checks for signs of damage, taking note of manufacturer instructions for inflation and maintaining equipment in a good state of repair.
Should a ball burst or a fall occur, maternity units should consider the wellbeing checks that need to be completed for mother and baby. These may include CTG monitoring and medical reviews. If the mother has fallen, consideration should be given to her safe retrieval from the floor to avoid potential neck or spinal injuries.
3. Hot water bottle burns
Searches were made on the NRLS following a non-obstetric incident involving a patient receiving full thickness burns from a leaking hot water bottle. There were 31 incidents involving hot water bottles and burns reported over a two-year period, and 11 of these occurred in a maternity setting.
Use of hot water bottles or hot packs for breakthrough pain in a maternity setting can be confounded by the lack of sensation that women experience with epidural anaesthesia. Consequently, they do not move and spread the focus of the heat, and are also unaware that their skin may be burning.
Women with epidural anaesthesia should be advised not to use any form of heat pack or hot water bottle because of the risk of burns. The application of heat would not confer any additional benefit with a functioning epidural; therefore any need for additional analgesia should prompt an anaesthetic review of the effectiveness of the epidural. Ensure that birthing partners or doulas
are also aware of this advice as they may well be providing heat packs to support their partners.
Karen Hooper is patient safety clinical lead, maternity and neonates for the national patient safety team at NHS Improvement
- For more information about the patient safety team’s work, visit the website at improvement.nhs.uk
- Read biannual ‘review and response’ reports at bit.ly/NRLS_reports
- Follow the Twitter feed for the latest news @ptsafetyNHS
Sharing best practice
Thank you to all those who have reported issues via your trust processes; I hope that this article has helped to demonstrate how what may seem a minor, isolated incident in your own area can translate into some valuable learning and improvements to patient care across the wider system. By learning and sharing best practice together, we can make the changes step by step.