Chapter 45 – Risk Management




Abstract




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].





Chapter 45 Risk Management Emergency Obstetric and Intrapartum Care



Jessica Moore




Key Facts




  • Obstetrics is a very high risk specialty associated with increased likelihood of patient safety incidents, mainly because this is the only specialty in which clinicians have to critically balance the interests of one human being (the mother) with that of another (the fetus), while providing care.



  • Continuation of pregnancy in the fetal interests may cause harm to the mother, and continuation of labour to reduce the risks of operative interventions to the mother may increase the likelihood of hypoxic-ischaemic injury to the fetus.



  • During the second stage of labour, the decision to perform an operative vaginal birth (vacuum or forceps) due to suspected fetal compromise may result in perineal trauma to the mother, resulting in patient-safety incidents.



  • Rapid evolution of events during labour requires rapid decision-making skills in a highly pressured, high-risk environment, which may contribute to adverse incidents.



  • Maternity care involves a multidisciplinary team approach involving midwives, obstetricians, neonatologists, anaesthetists, haematologists, physicians, cardiologists, and other allied specialties. Therefore, issues with communication, culture and team as well as task factors may contribute to patient safety incidents.



What Is Risk Management?


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].


An additional driver for the development of risk management arose from the rising litigation in obstetrics. In the United Kingdom in 2017–18, although the number of claims in obstetrics made up only 10% of the total number of claims, the value of these claims was almost 50% of the total costs paid out in that time [4].


The momentum within the risk management process has put safety very much in the public arena with high-profile campaigns such as Each Baby Counts and the desire to learn on a national scale and not just in individual institutions.



The Importance of Risk Management


The concept of patient safety is well accepted, as is the fact that this is a collective responsibility, hence the importance of all clinicians to understand the processes and function of risk management. It is wrong to think of risk management as just being the concern of the risk management team and not everybody. Individuals have a responsibility to know what the risks are where they work and to be pro-active in reporting patient safety concerns. It is also wrong to think that risk management is just about blaming individuals when there has been an adverse outcome. While individuals may often feel a huge burden of individual responsibility when there has been a poor outcome, the risk process should be more focused on looking at the systems in which the individuals are working.


It is also important to look at the wider impact risk management has in terms of protecting clinicians by allowing them to practice safely. The psychological impact that an adverse outcome will have on staff has been increasingly recognised, which may affect their working practice and general wellbeing [5]. Leading on from this, there may also be negative media interest and reputational damage for an institution.


While patient safety is at the heart of risk management there is also a financial cost which cannot be ignored. It is well known that litigation in maternity is the highest of all specialties due to the costs of looking after a brain damaged child.



What Are the Risks in Emergency and Intrapartum Care?


Obstetric emergencies can result in maternal and perinatal morbidity and mortality. Even the best maternity departments will experience adverse outcomes, some of which were anticipated and others not. Many maternity units will have a defined set of risks and incidents which will automatically trigger an investigation.


Examples are shown in Table 45.1




Table 45.1 Common risks that should trigger a ‘Risk Management’ investigation









































Clinical risk Non-clinical risk
Postpartum haemorrhage Lack of staff or wrong staff mix
Shoulder dystocia Faulty equipment
Third-degree tear Lack of guidelines
Maternal collapse
Uterine rupture
Umbilical cord prolapse
Unexpected neonatal unit admission
Intrapartum stillbirth
Drug error
Retained swab

Some emergencies may be frequently encountered on the delivery suite, such as postpartum haemorrhage (PPH). These emergencies are well known to the healthcare professionals working on a delivery suite or in a birth centre and they will be familiar with the guidelines on how to manage the problem. There may also be tools such as a haemorrhage proforma to act as an aide memoir and to ensure good documentation of the management. However, even with an emergency such as PPH it is still important to scrutinise the details to establish if the correct steps were taken, in a timely manner, and whether anything could have contributed to the haemorrhage, for example, delay in taking a patient to theatre with a retained placenta.


There are other emergencies such as maternal cardiac arrest that happen infrequently. Such events are often not anticipated and can be very challenging for staff having not dealt with it previously. These emergencies are often practised through simulation drills.



Incidence of Risk Events


It is hard to provide data on the incidence of risk events in obstetrics, as the definitions used may vary. There may also be poor reporting of risk events, especially near misses, where an adverse outcome was avoided but the issue has the potential to recur and cause harm. There is some evidence for the overall frequency for suboptimal outcomes to occur in about 8% of deliveries [6]. However, an individual unit should know their incidence of risk events and tools like a maternity dashboard can help with the monitoring of the incidence. For example, if there is a sudden increase in the incidence of third-degree tears the department needs to investigate the reason for this. A maternity dashboard also allows all the staff in a department to understand what the risks are in their department.


In the United Kingdom there is increasing national scrutiny on certain risk events borne out by national audits such as the National Maternity and Perinatal Audit which collects data from individual trusts, allowing them to benchmark themselves against other trusts. These data are all in the public domain, which increases transparency for patients.


The confidential enquiries by MBBRACE investigate maternal and perinatal deaths to allow the learning to be disseminated at a national level.



Key Pointers




  • The patient and her safety must be the focus of risk management.



  • Adverse incidents will occur during intrapartum care, especially during obstetric emergencies; hence everyone working in this area must learn from these incidents.



  • Individuals have a responsibility to participate and embrace the risk management process to ensure we learn from poor outcomes.



  • Risk management is important at an individual, local, regional and national level.



  • Risk management is a multidisciplinary process. The obstetric risk management team should include a senior obstetrician, midwife, anaesthetist, neonatologist and service managers. It is important to include trainees to ensure they are represented and to ensure that risk management is seen as a vital part of obstetric practice.



  • Obstetric risk management will often be overseen by the hospital risk managers who report to the commissioners. This ensures there is accountability and that there is inter-departmental learning.



  • Risk management involves the analysis of prospective and retrospective risk events. This ensures potential risk are dealt with before they occur and when a risk event does occur that lessons can be learnt to prevent recurrence.



  • Good risk management looks at system rather than individual ‘failures’ contributing to a risk event. There is increasing interest in the so-called ‘human factors’ in risk management.



  • Successful risk management arises from good leadership to embed risk management into everyday practice.



Key Implications


The key implications of risk management are




  • The safety of patients – mother and baby



  • To learn from mistakes and avoid repeating them



  • To look at systems and not individuals who contribute to an adverse outcome



  • To improve the workplace for staff by avoiding errors


There is evidence that good risk management can make a difference in terms of safer patient care. In the United Kingdom the largest maternity unit has achieved a 11% reduction in the number of clinical incidents where there was felt to be a degree of substandard care following the introduction of a comprehensive risk management strategy [7].


Adverse outcomes from obstetric emergencies can affect




  • Mother and baby



  • Partner and family



  • Healthcare professionals – those directly and indirectly involved



  • Departmental managers



  • Reputation of a department or hospital


These effects may be




  • Physical in terms of morbidity and mortality



  • Psychological



  • Financial



Key Actions: The Risk Management Process


When looking at the risk management process it is useful to remember that risk events may be investigated in two ways:




  • Retrospectively or reactively: the investigation of an adverse incident after the event has occurred



  • Prospectively or pro-actively: anticipation of risk events


It is very important to be aware that risk management is not just about investigating cases with an adverse outcome.


There are four key steps in the risk management process [8]:




  • Identification of risk event



  • Analysis of risk event



  • Treatment of risk events



  • Measures to control risk events



Identification of Risk

The identification of risk events may come from local sources within a department or external sources such as national audits.

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May 9, 2021 | Posted by in OBSTETRICS | Comments Off on Chapter 45 – Risk Management
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