The report aims to help improve patient safety by tracking national data relating to the most common patient safety incidents and claims in maternity and gynaecology services, and provides recommendations for improvements in incident reporting and safety measures.
New analysis of Irish maternity services
The 19 Irish maternity services are compared for the first time from a clinical incident and claims rate perspective. National data is contextualised with international published figures from peer reviewed medical journals and international reports where available and appropriate.
The report also analyses 10 years of closed claims in relation to retained foreign bodies in maternity and gynaecology services. The results of the first national survey on modes and patterns of incident reporting by acute hospitals are also reviewed.
The four key components of the report are:
- Maternity services: patient safety incidents, claims and total cost
- Gynaecology services: patient safety incidents, claims and total cost
- A 10-year review of closed claims pertaining to retained foreign bodies in maternity and gynaecology services nationally
- A national survey of the modes and patterns of incident reporting in acute hospitals nationally
State Claims Agency Director Ciarán Breen said:
“The Agency is acutely conscious that behind the statistics contained in this report are tragic events that have resulted in suffering and acute trauma for expectant mothers, their babies and their families.
However, this report is valuable because it analyses crucial information on adverse event reporting in maternity and gynaecology services. This information assists in the identification of adverse trends and areas for improvement in the maternity and gynaecology services.
Since the rollout of the new national incident management system (NIMS), the Agency has now available to it increased IT capabilities allowing it to produce reports such as this into the handling of adverse event recording and claims management. The Agency will continue to work closely with the HSE and voluntary hospitals on the implementation of NIMS and on improving the quality of reporting.
Among the report’s key observations is that variation in patient safety incident reporting exists nationwide and a lack of standardisation exists regarding reporting of severity of injury in relation to patient safety incidents. It is anticipated that better quality and more consistent reporting will result from healthcare enterprises becoming more familiar with the new National Incident Management System (NIMS) which was launched in 2014.”
Maternity Services Incidents, Claims and Cost
- The national incident rates in Irish maternity services are not dissimilar to international figures where comparisons are available.
- While 75 clinical incidents (out of a total of 9,787 incidents) rated as extreme in severity were reported by maternity services to NIMS in 2014, these were not all avoidable clinical incidents causing harm. Some related to unavoidable natural events, significant congenital anomalies or mis-categorisation regarding severity factor.
- The six most common maternity claims were categorised as: perineal tear (3rd & 4th degree, incl. breakdown of perineum); shoulder dystocia; stillbirth; unexpected neonatal death; cerebral irritability/neonatal seizure; and “other”. The claim count has remained either static or has reduced since 2012 for these categories.
- Total expenditure on clinical claims in maternity services was 54% of all clinical care related claims in 2014. Total expenditure on maternity related claims has increased 80% from €32 million in 2010 to €58 million in 2014.
- Total expenditure on cerebral palsy claims increased 77% from €27 million to €47 million between 2010-2014. This increase is primarily due to lump sums replacing certain previous Periodic Payment Orders (PPOs) and to the cumulative effect of the greater use of PPOs over time.
- A high rate of incident reporting in a service is nationally and internationally regarded as being reflective of a culture of strong patient safety. Comparison of the 19 Irish maternity services shows variation exists nationally across maternity services regarding clinical incident reporting. This new data will enable services to bench mark themselves against both the median and other services of similar activity regarding incident reporting and claims.
Gynaecology Services Incidents, Claims and Cost
- The six most commonly occurring incidents in gynaecology services between 2010 and 2014 were: unplanned re-attendance; missing or misplaced clinical records; patient falls without supervision; failure or faulty medical devices or equipment; delayed or cancelled surgery; and “other”.
- Delayed /cancelled surgery increased by 10 fold. Cancelled surgery is both a national and international issue.
- There has been an increase in unplanned re-attendance and failure/faulty medical device/equipment, while falls without supervision; healthcare records missing or misplaced; incomplete data and incorrect data have reduced slightly.
- Total expenditure on claims in gynaecology services was €4.2 million which equates to c.4% of total expenditure on clinical care claims in 2014.
10-year review of Closed Medico-Legal Claims for Retained Foreign Bodies
- There were 30 closed claims for retained foreign bodies nationally in maternity and 14 in gynaecology services between 2004 and 2014.
- Ensuring implementation of best practice guidelines is critical to improving the incidence of retained foreign bodies – these include implementation of a specific counting protocol for sharps and swabs pre and post vaginal delivery, similar in standard to that of an operating theatre, and implementing a quality improvement programme which ensures each retained foreign body case or near miss is investigated thoroughly.
Modes and Patterns of Reporting
- The majority (n=49, 96%) of acute hospitals nationally in the first quarter of 2015 reported to NIMS, one (2%) did not. This has since been rectified.
- Six (12%) acute hospitals dual report i.e. they report to two incident-reporting systems, which is inefficient.
- Nine (18%) acute hospitals report only 50% or less of the incidents notified to them to the SCA. The majority (n=38, 76%) of acute hospitals responded that they report between 75-100% of incidents to the SCA.
- In the majority (n=34, 68%) of acute hospitals, one month is the “delay time” before an incident, notified to an acute hospital, is reported to the SCA. Of these 34, 16 (32%) acute hospitals notify SCA within one week, 13 (26%) within two weeks and five (10%) within four weeks.
- A backlog of incidents to be notified to the SCA exists in just over half of acute hospitals (n=26, 52%) nationally. The volume of the backlog is less than 100 incidents in 12 hospitals but greater than 500 in six hospitals.
- Variation exists nationally across the acute hospitals regarding different modes and patterns of reporting incidents to SCA.
Dr Dubhfeasa Slattery, Head of Clinical Risk, State Claims Agency and author of the report said:
“The purpose of this report is to help improve patient safety and experience by highlighting the most common clinical incidents and claims, tracking them over time to identify trends /patterns and by providing some risk management recommendations to help prevent clinical incidents occurring.
Throughout the writing of this report, the difficult journeys of mothers, babies, families and women with gynaecological symptoms in Ireland was central. This is a first step in providing detailed baseline data regarding maternity and gynaecology clinical incidents and claims pertaining to maternity and gynaecology services, promoting further transparency into the future.
Increased reporting of clinical incidents will help the identification of trends and patterns in an institution regionally and nationally.
The SCA is dedicated to working with maternity and gynaecology services nationally to improve patient safety and experience through encouraging more uniformity in incident reporting. This will ensure trends are identified sooner so that risk management recommendations may be instituted, harm may be prevented and patient safety promoted. Good quality data is critical.”
The report is available to view below.