To increase the the quality of health care.......... Risk management in labour is vital as it is connected with two lives. So it is the responsibility of the health care providers to assure it.........

1. Clinical risk
management in labour
Amila Weerasinghe
&
Channa Gunasekara
of
Faculty of Medical Sciences,
University of Sri Jayewardenepura,
Sri Lanka.
2014/09/8

2. Definition
• Clinical risk management can be defined as
organizational systems or processes that aim
to improve the quality of health care and
create and maintain safe systems of care..
• In obstetrics , it is particularly important as it
is a high risk specialty and the cost of
mistakes is high, both financially and in
human terms.

3. • Aim
To improve standards of care and
subsequently reduce the harm occurring to
woman and their babies.
So eventually, it should decrease number of
complains and the cost for litigations.

4. • Human error is inevitable, so there is a need
to understand the theory of human error and
the systems, rather than person-centred,
approach to dealing with adverse events.
• ‘We cannot change the human condition, but
we can change the conditions under which
humans work.’
Reason J. Managing the Risks of Organizational Accidents.
Aldershot: Ashgate; 1997.

5. Principles of risk management
The following need to be recognized when considering
medical error:
• uncertainty of clinical practice;
• nature of clinical decisions;
• benefits of hindsight;
• frequency of activity;
• error-producing conditions under which we work;
• fact that people do not intend to commit errors;
• that accidents are rarely due to single errors but are
the product of multiple factors;
• that the psychological precursors of error are the last
and least manageable stages in the accident chain.

6. Types of errors

7. • Slips and lapses
 recognition: e.g. the
cardiotocograph (CTG);
 attention: interruptions and distractions from the
task;
 memory: something is forgotten;
 selection: the wrong medication is chosen from a
number of ampoules that look the same.

8. • Mistakes
 Rule based: eg; syntometrine is given for
active management of the third stage in a
woman with hypertension and she
subsequently has a fit. A good rule is used in
the wrong situation.
 Knowledge based: There is not a known
preplanned course of action. A plan is worked
out to deal with this, but it does not have the
desired effect.

9. • Violation
 Routine: cutting corners, e.g. not logging off the
computer;
 Reasoned: the only option in the circumstances,
such as a trial of forceps for fetal bradycardia in the
delivery room as the theatre is busy;
 Reckless: harm is foreseeable but not intended,
e.g. using multiple instruments in a trial of
instrumental delivery;
 Malicious: deliberately harmful: motivated by or resulting
from a desire to cause harm or pain to another.
eg: such as the recently publicized case of the GP
Harold Shipman.

10. Plight of Sri Lanka
• Though there are general rules and bylaws
introduced by certain authorities;
Such as SLMC , Ministry of health , civil law…. Etc
There isn’t a proper clinical risk management
program conducted by any responsible
authority.

11. What are the components should be
there to establish an effective clinical
risk management in labour ?

13. • Organizational culture
• Learning from adverse incidents
Liam Donaldson, Chief Medical Officer, has said in
relation to this that ‘To err is Human. To cover up
is unforgivable. To fail to learn is inexcusable.
• Medical and midwifery staff
are encouraged to report when
things go wrong.
1. Antenatal clinics
2. On the delivery suite
3. On the obstetric wards

15. • Risk assesment
Aims to identify risks before adverse events occure
and put into place procedures, barriers and other
measures to reduce these risks.
Personnel: staffing levels, skill mix and training;
 Estate: a safe environment for staff and patients;
 Equipment: CTG machines, infusion pumps, etc.;
 Practice: policies and procedures.

17. •Training, induction and competence
Inexperience increases the risk of error four-fold,
so training is extremely important in risk
management.
eg :- CTGs - formal teaching sessions, CTG review
meetings and electronic training packages.

18. • Resuscitation- Both adult and neonate. all
maternity staff know how to deal with collapse
while awaiting the arrival of the crash team.

19. • Drills - for shoulder dystocia,vaginal breech
delivery, cord prolapse, eclampsia and massive
haemorrhage.
• Equipment - Matrices are useful in identifying
which members of staff need training on
particular items of equipment; those who are
not trained must not use them.
• Supervised practice - This allows staff to
develop their skills and allows competencies
to be assessed while minimising the risk to
patients.

20. •Guidelines
• Greentop / RCOG
• Nice
• SLCOG

21. •Communication
Communication with the patient
• Consent should be taken adequately for procedures.
• Patients must be given enough information about
the procedure and its risks, benefits and
alternatives to make an informed decision about it.
• Patients who are mentally competent have the right
to refuse treatment even if that might result in harm
to themselves or the death of their baby.

22. Communication between professionals

23. • This needs to encompass communication
between the hospital services and community
and primary care.
• All the relevant professionals must be kept
informed of the plan of care and any
complications.
• Adequate discharge information is essential.
• Documentation must be legible, dated and
signed. It should include the discussions that have
taken place with the patient and a management
plan, and key individuals should be identified.

25. •Audit
 Audit of labour ward outcomes can detect if
guidelines are not being followed or certain
standards are not being met.
Repeat audit should show improvements
occurred due to actions taken.

27. Resources for reducing the risk on labour wards
• National Patient Safety Agency [www.npsa.nhs.uk] Excellent site with good resources on
patient safety including e-learning modules on patient safety and root cause analysis.
• NHS Litigation Authority [www.nhsla.com] Facts and figures on claims for negligent harm.
• Medical Devices Agency [www.medical-devices.gov.uk] Provides updates and alerts for
medical devices. Also gives articles and reviews about specific risks, e.g. infusion devices.
• World Health Organization [www.who.int/patientsafety/en] Setting the international
agenda for patient safety.
• Institute for Safe Medication Practices: Canada [www.ismpcanada.org] Resources
include safety publications including alerts and bulletins, surveys, andinformation on the
Canadian Medication Incident Reporting and Prevention System (CMIRPS).
• Australian Council for Safety & Quality in Health Care [www.safetyandquality.org] This
site provides an overview of the patient safety agenda in Australia, including news reports,
publications, resources, events and areas for action in patient safety.
• American College of Obstetricians and Gynecologists
[www.acog.org/from_home/departments/dept_notice. cfm?recno=28&bulletin=2491]
American College website on quality and patient safety with a series on patient safety tips.
• National Patient Safety Foundation [www.npsf.org] Access to US sites on patient safety.
Excellent resources for involving patients in safety.