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A dedicated, national report, Clinical incidents and claims report in Maternity and Gynaecology services, a 5 year review: 2010-2014, was published by the State Claims Agency (SCA) in October 2015.

The aim of this report is to help improve patient safety, quality of care and the patient experience by outlining detailed, national, clinical data on patient safety incidents, claims and cost, tracked over a 5 year period. This report provides an in depth review of the most common clinical incidents and most common and costly claims, adjusted for activity and contextualised, where possible, with international data from peer reviewed scientific journals and national reports.

Total expenditure paid was reviewed in detail over a 5 year period. The 19 public maternity hospitals were compared in an anonymised manner from a patient safety incident and claims’ rate perspective.

A detailed analysis of 10 years of closed claims pertaining to retained foreign bodies in maternity and gynaecology services was performed and results presented. Results of a national survey carried out in 2015 of the modes and patterns of incident reporting by acute hospitals nationally to the SCA were shared.1

General Results

Variation and lack of standardisation in patient safety incident reporting and quality of reporting was identified. Lack of uniformity exists across the 19 maternity hospitals in relation to the reporting of severity of injury, particularly in relation to incidents rated as extreme. While the quality of the data reported to the SCA is often good, at times, it is suboptimal. Some mis-categorisation of incidents was identified where incidents were rated by services as extreme, but “no harm/injury” had been sustained. Overall, this variation and lack of standardisation regarding incident reporting makes comparisons between maternity and gynaecology services nationally inaccurate.

Maternity Services

Out of a total of 9,787 incidents, which occurred in maternity services in 2014, reported to SCA, 9,397 (96%) were clinical.1 Seventy five were rated extreme by the maternity services, but detailed clinical and manual analysis revealed that the true number of extreme incidents was less than 75.

The most common incidents which occurred between 2010-2014, in decreasing frequency, is “other” (the category used when none of the known categories applied to the incident), followed by post partum haemorrhage, 3rd and 4th degree perineal tear, apgar score < 5 at 1 minute, 7 at 5 minutes, cord base excess < 12 and pH<7.2, unexpected transfer to the special care baby unit (SCBU) or neonatal intensive care unit (NICU), unplanned re-attendance and shoulder dystocia.

Between 2010-2014, post partum haemorrhage and unplanned re-attendance have increased in number while perineal tear, unexpected transfer to the SCBU/ NICU have remained relatively stable and infants with low apgar score and low cord pH have almost halved.1

In 2014, 140 claims were created in maternity services of which 137 (98%) were clinical. The most common claims in maternity services between 2010-2014 were “other”, perineal tear and shoulder dystocia (all 3 of which are decreasing over this time period), still birth, unexpected neonatal death and cerebral irritability.

Total expenditure paid on clinical claims in maternity services was 54% (€57.3 million)* of all clinical care related claims in the year 2014 (€106 million).1 Cerebral palsy accounted for €47 million paid in 2014.1

In 2014:

140 Maternity Services Claims

98% = Clinical

Total paid 57.3million

33 Gynaecology Claims

100% = Clinical

Total paid 4 million

Gynaecology Services

Out of a total of 1,403 incidents reported, 11 (0.8%) were rated extreme. The most common incidents which occurred between 2010-2014, included: unplanned re-attendance, delayed or cancelled surgery and failure/faulty medical equipment, all 3 of which have increased, while patient falls (unsupervised), missing healthcare records/misplaced incomplete/incorrect data and the category “other” have decreased. In 2014, 33 gynaecology claims were created, all of which were clinical.

The most common claims between 2010-2014 (excluding mass actions), included: unexpected complications following an operation/procedure, unintentional laceration to an organ, delayed diagnosis and retained or missing swab/needle/device. Total expenditure paid on gynaecology claims in 2014 was €4 million.

Closed Claims

Medico legal claims closed between 2004-2014 related to retained foreign bodies in maternity and gynaecology services were analysed in detail.1 Despite multiple interventions, retention of foreign bodies remains both a national and international opportunity for improvement.1

Reporting to the State Claims Agency

Variation was identified regarding the modes and patterns of incident reporting by acute hospitals nationally to the SCA including: the percentage of incidents reported (range 10% to 75-100%), the backlog of incidents (<100 to >1,000 incidents), and time delay in reporting to the SCA (range 1 week to 6 months). Surprisingly, five hospitals were unaware of the statutory obligation to report adverse events to the SCA.

The findings in this five year review were presented to Minister Varadkar at the NTMA in August 2015 and the report was published October 20th 2015 and disseminated to all stakeholders.

*Figures rounded

Article by: Dr Dubhfeasa Slattery, MB BCH, MRCPI(Paeds), FCPI, M Med Sci, PhD, Head of Clinical Risk, State Claims Agency

References available on request

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