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Labour and Delivery Posters
Analysis of 772 reported ‘death’ and ‘severe’ obstetric and neonatal incidents from the United Kingdom NPSA national reporting and learning system (NRLS)
  1. J Sandall,
  2. K Watson,
  3. O Wiseman
  1. Women's Health Academic Centre, King's Health Partners, King's College, London, London, United Kingdom

Abstract

Introduction The NPSA National Reporting and Learning Service (NRLS) receives notification on patient safety incidents including those from obstetric and neonatal services. There has been no published analysis of a full obstetric and neonatal incident dataset.

Methods A dataset was extracted from the NRLS database for all incidents in 2009 within specialty codes ‘obstetric’ or ‘neonatal’ and classified as ‘death’ or ‘severe’. Of 9,121 incidents 238 (3.7%) were coded as death and 524 (5.7%) were coded as severe. Data was analysed using NRLS incident categories and secondary coding was done according to primary outcome of incident and degree of harm. Further analysis was undertaken of 173 incidents identified as containing potentially avoidable factors.

Results Data came from 133/180 (74%) of obstetric units in England and Wales. A total of 264 potential avoidable factors were grouped into themes. Secondary analysis found a total of 264 separate occurrences of potential avoidable factors which grouped into 10 themes. Major themes were: failure or delay to monitor, diagnose or assess; delay or failure to recognise deterioration and/or escalate to appropriate members of staff; and concerns with resources, staffing and equipment. Key fields such as mode of delivery were not mandatory, and there was inadequate information regarding avoidable factors.

Conclusion Caution is needed when using the NRLS database for analysis of obstetric and neonatal incidents. Lessons to improve future care are limited when key information is missing. Delay and failure to monitor, to recognise deterioration and escalate continue to be concerns within maternity.

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