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Showing results for tags 'Baby'.
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Content Article
Clinical governance is the system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical excellence will flourish. Clinical governance encompasses quality assurance, quality improvement and risk and incident management. These guidelines cover responsibilities, programme standards and performance monitoring, quality assurance, quality improvement, and risk and incident management. -
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National Learning Reports offer insight and learning about recurrent patient safety risks in NHS healthcare that have been identified through HSIB investigations. They present a digest of relevant, previously investigated events, highlight recurring themes and, where appropriate, make safety recommendations. National learning reports can be used by healthcare leaders, policymakers and the public to aid their knowledge of systemic patient safety risks and the underlying contributory factors, and to inform decision making to improve patient safety. The Healthcare Safety Investigation Branch (HSIB) Summary of themes arising from HSIB maternity investigation programme report (March 2020) describes eight themes arising from the maternity investigations. Sudden unexpected postnatal collapse (SUPC) was identified as a theme for further exploration in order to highlight areas of system-wide learning. SUPC is a rare but potentially fatal event in otherwise healthy appearing term (born after 37 completed weeks) newborn babies at birth. Between April 2018 and August 2019 HSIB completed 335 maternity investigations. Of the 12 identified SUPC cases, there were 6 cases where positioning of the baby to achieve skin-to-skin contact may have contributed to SUPC. While the number of incidents found was small compared to the number of term babies who had skin-to-skin contact at birth these incidents may in future be avoided and so learning is essential.- Posted
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- Baby
- Obstetrics and gynaecology/ Maternity
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In this edition of the Nursing and Midwifery Council's (NMC) public newsletter, we hear from Sarah Seddon, who was a witness in a fitness to practise investigation following the tragic loss of her baby. She shares how this process felt and how she is using her personal experience to help the NMC work in a more person-centred way.- Posted
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The goal of this US-based study, published in Psychiatric Services, was to characterise racial-ethnic differences in mental health care utilisation associated with postpartum depression in a multi-ethnic cohort of Medicaid recipients. Medicaid in the United States is a federal and state program that helps with medical costs for some people with limited income and resources. Findings of the study presents evidence of low rates of postpartum depression treatment initiation and continuation, indicating barriers to care among low-income mothers; racial-ethnic disparities imply additional challenges for black women and Latinas. The presence of such disparities points to the need for clinical and institutional policies and programs to address the particular barriers to mental health care faced by black women and Latinas in the months after delivery.- Posted
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- Obstetrics and gynaecology/ Maternity
- Maternity
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Content Article
This paper, from THIS Institute, aims to describe exactly what needs to happen for maternity care to be safe by examining how interventions and context work together to nurture and sustain safe practice.- Posted
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- Obstetrics and gynaecology/ Maternity
- Maternity
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The Obs Pod, by obstetrician Florence Wilcock
PatientSafetyLearning Team posted an article in Maternity
This series of podcasts, supported by the Maternity Experience (#MatExp), is produced by Florence Wilcock. She explores different topics within maternity, aiming to ignite positive change and action.- Posted
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- Obstetrics and gynaecology/ Maternity
- Quality improvement
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More women are choosing to birth at home in well-resourced countries. Concerns persist that out-of-hospital birth contributes to higher perinatal and neonatal mortality. This systematic review, published by The Lancet, and meta-analyses determines if risk of fetal or neonatal loss differs among low-risk women who begin labour intending to give birth at home compared to low-risk women intending to give birth in hospital.- Posted
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- Obstetrics and gynaecology/ Maternity
- Maternity
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The group B Strep i-learn module
PatientSafetyLearning Team posted an article in Maternity
Group B Strep can be a complex topic, with some confusion about what exactly is the latest guidelines on testing, risk factors, recommended antibiotics, and the impact (if any) of GBS on homebirths, waterbirths, breastfeeding, and much more.This is why Group B Strep Support and the Royal College of Midwives (RCM) have produced an evidence-based group B Strep i-learn module.The group B Strep i-learn module focuses on the current UK guidelines for preventing group B Strep infection in newborn babies and on signs of these infections in babies. It will refresh clinician knowledge of the national guidelines, and help you tackle the FAQs you get from expectant and new parents.Follow the link below to find out how to sign up.- Posted
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- Infection control
- Risk management
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Content Article
Group B streptococcus (GBS) is a naturally occurring bacterium, often found in the mother’s vagina, which can be dangerous for babies during labour and immediately after birth. The mothers carry this bacterium in the birth canal without any problem to themselves. Giving antibiotics to the mother during labour reduces the incidence of GBS infection passing on to the baby (National Institute for Health and Care Excellence, 2012).- Posted
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- Organisational learning
- Maternity
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COVID-19 has created unprecedented pressures for the NHS as a whole including maternity services. How can maternity leaders run a safe and rights respecting maternity service during a pandemic? This guide, produced by Brithrights, sets out a process to support maternity service leaders to reach decisions that help them to achieve this. All those affected by decisions need to be involved in making them. NHS England guidance states that Maternity Voices Partnership Chairs should be involved in decisions about temporary changes to maternity services, in addition to staff and partner organisations. -
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NHS leaflet: Illness in newborn babies
PatientSafetyLearning Team posted an article in Maternity
After babies are born they have to breathe, suck, feed, wee, poo and stay warm. This NHS leaflet (April 2020) will tell you how to keep your baby safe and healthy. Do not delay seeking help if you have any concerns. Content includes: What is jaundice? Breathing, colour and movement. Feeding.- Posted
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- Monitoring
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Premature Waters Breaking (PPROM awareness)
PatientSafetyLearning Team posted an article in Maternity
PPROM is the acronym for Preterm Pre-labour Rupture Of Membranes. This is otherwise known as when the waters break prior to 37 weeks during pregnancy. These waters, known as the amniotic fluid, protect the baby from injury. It also helps in preventing infection being passed from mother to baby. As soon as the waters break the risks of infection to both mother and baby are high. Therefore good management of care at this stage is key to treating this condition successfully. Little Heartbeats raise awareness of PPROM, help patients share their experiences and promote the use of the Royal College of Obstetricians and Gynaecology leaflet which contains the guidelines set out for UK hospitals to follow in the event of PPROM. -
Content Article
This Review was announced in the House of Commons on 21 February 2018 by Jeremy Hunt, the then Secretary of State for Health and Social Care. Its purpose is to examine how the healthcare system in England responds to reports about harmful side effects from medicines and medical devices and to consider how to respond to them more quickly and effectively in the future. The Review was asked to investigate what had happened in respect of two medications and one medical device: hormone pregnancy tests (HPTs) – tests, such as Primodos, which were withdrawn from the market in the late 1970s and which are thought to be associated with birth defects and miscarriages; sodium valproate – an effective anti-epileptic drug which causes physical malformations, autism and developmental delay in many children when it is taken by their mothers during pregnancy; and pelvic mesh implants – used in the surgical repair of pelvic organ prolapse and to manage stress urinary incontinence. Its use has been linked to crippling, life- changing, complications; and to make recommendations for the future. The Review was prompted by patient-led campaigns that have run for years and, in the cases of valproate and Primodos over decades, drawing active support from their respective All-Party Parliamentary Groups and the media.- Posted
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- Medical device
- Medication
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Risks of CTG monitoring
PatientSafetyLearning Team posted an article in Maternity
This is a series of three articles written by Kirsten Small, a specialist obstetrician and gynaecologist in Australia, exploring the risks that flow from the use of intrapartum monitoring. Part 1 Examines evidence of short and long-term physical harms to birthing women relating to higher rates of surgical birth when intrapartum Cardiotocography (CTG) monitoring is used. Part 2 Focuses on possible psychological harms which have been reported relating to CTG use. Part 3 Looks at the possibility that CTG use might cause harm to the baby, while the two previous posts have examined the risk to birthing women.- Posted
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- Maternity
- Obstetrics and gynaecology/ Maternity
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Content Article
In this candid blog, 'The Secret Midwife', gives her account of the pressure and lack of resource and support that makes it so difficult to provide safe care.- Posted
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- Obstetrics and gynaecology/ Maternity
- Maternity
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Content Article
At seven months pregnant, intensive care doctor Rana Awdish suffered a catastrophic medical event, haemorrhaging nearly all of her blood volume and losing her first child. She spent months fighting for her life in her own hospital, enduring a series of organ failures and multiple major surgeries. Every step of the way, Awdish was faced with something even more unexpected and shocking than her battle to survive: her fellow doctors’ inability to see and acknowledge the pain of loss and human suffering, the result of a self-protective barrier hard-wired in medical training. In Shock is her searing account of her extraordinary journey from doctor to patient, during which she sees for the first time the dysfunction of her profession’s disconnection from patients and the flaws in her own past practice as a doctor. Shatteringly personal yet wholly universal, it is both a brave roadmap for anyone navigating illness and a call to arms for doctors to see each patient not as a diagnosis but as a human being. -
Content Article
Despite increasing recognition of the potential risks associated with in-hospital newborn falls among health professionals, new parents are frequently unaware of the possibility of dropping their newborn, especially in the hospital. Although most newborn falls do not result in lasting harm to the newborn, they may need additional healthcare services and cause stress to the parents.- Posted
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- Baby
- Obstetrics and gynaecology/ Maternity
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Content Article
Letter from America: Kick off to a new year of hope
lzipperer posted an article in Letter from America
Football is a popular American pastime. Its focus on collaboration, individual skill reliance and teamwork serves as a touchpoint for the January 2020 Letter from America. Letter from America is a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States.- Posted
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- Teamwork
- Collaboration
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This article, published by Medium, looks at the story of a woman who had a stroke while pregnant. Both survived. The authors highlight a growing concern that the US is in the midst of a maternal morbidity and mortality crisis.- Posted
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- Maternity
- Obstetrics and gynaecology/ Maternity
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Content Article
In her blog for the Professional Standards Authority, Sarah Seddon talks about her personal experience as a patient going through the fitness to practise process. She outlines her thoughts on the key considerations that she believes regulators should take into account to help 'humanise' the process. "I was known as ‘Woman A’. To me, this embodies the entire impersonal, inhumane world of fitness to practise. I wasn’t a person with needs, thoughts and feelings; I wasn’t a bereaved mum; I wasn’t a professional anymore but simply a piece of evidence."- Posted
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- Accountability
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Content Article
Published in Acta Paediatrica, the parents of a baby who was born prematurely and died, share their experiences of the communication and choices given to them before the birth.- Posted
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- Baby
- Obstetrics and gynaecology/ Maternity
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Content Article
Re-writing conversations
Claire Cox posted an article in By patients and public
The language we use in healthcare can have a huge impact on our patients and families. What we say and how we say it could have a negative or a positive impact. As clinicians we need to be mindful in how we say things and relay information. This short blog illustrates this.- Posted
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- Communication
- Culture of fear
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Baby’s death from heart defect was avoidable (August 2019)
Claire Cox posted an article in PHSO investigations
The Parliamentary and Health Service Ombudsman (PHSO) were set up by Parliament to provide an independent complaint handling service for complaints that have not been resolved by the NHS in England and UK government departments. They share findings from casework to help Parliament scrutinise public service providers. They also share their findings more widely to help drive improvements in public services and complaint handling. Miss K complained to the PSHO about the care and treatment that her son, Baby K, received at the Trust in November 2015. She said that the Trust failed to act following various checks on Baby K, and it failed to escalate his care in line with the seriousness of his condition and he died as a result. Miss K also complained about the Trust’s handling of her complaint.- Posted
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Consent: The Montgomery Ruling (2015)
Claire Cox posted an article in Consent issues
The Montgomery case in 2015 was a landmark for informed consent in the UK. Nadine Montgomery, a diabetic woman and of small stature, delivered her son vaginally; her son experienced complications owing to shoulder dystocia, resulting in hypoxic insult with consequent cerebral palsy. Her obstetrician had not disclosed the increased risk of this complication in vaginal delivery, despite Montgomery asking if the baby's size was a potential problem. Montgomery sued for negligence, arguing that, if she had known of the increased risk, she would have requested a caesarean section The Supreme Court of the UK announced judgement in her favour in March 2015. It established that, rather than being a matter for clinical judgment to be assessed by professional medical opinion, a patient should be told whatever they want to know, not what the doctor thinks they should be told. This ruling means that patients can expect a more active and informed role in treatment decisions, with a corresponding shift in emphasis on various values, including autonomy, in medical ethics- Posted
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- Consent
- Perception / understanding
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Each baby counts: Aims and objectives
Claire Cox posted an article in Maternity
In the UK, each year over 1000 babies die or are left with severe brain injury, not because they are born too soon or too small, or have a congenital abnormality, but because something goes wrong during labour. The Royal College of Obstetricians and Gynaecologists does not accept that all of these are unavoidable tragedies, and with the Each baby counts project, they are aiming to reduce this unnecessary suffering and loss of life by 50% by 2020.- Posted
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- Delivery suite
- Maternity
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