Best practice & research. Clinical obstetrics & gynaecology
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Best Pract Res Clin Obstet Gynaecol · Aug 2013
ReviewThe recurring problem of retained swabs and instruments.
Patient safety is one of the most pressing challenges in health care. The promotion of safety requires that all those involved in healthcare realise that the potential for errors exists, and that teamwork and communication are essential for preventing errors. Incidents compromising patient safety, such as unintended retention of swabs or instruments, are regarded as 'never events'. ⋯ One estimate says that one case of a retained item occurs at least once a year in a major hospital where 8000 to 18,000 major cases are carried out each year. All healthcare organisations should take appropriate measures to prevent retention of foreign bodies by consistent application of reliable and standardised processes of care. In this review, we explore the risks and complications associated with retained swabs and instruments, and different ways to prevent such risks to patients.
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Best Pract Res Clin Obstet Gynaecol · Aug 2013
ReviewReducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies.
Poor teamwork results in preventable morbidity and mortality for mothers and babies. Suboptimal communication and lack of leadership cost not only lives but also money that is diverted from clinical care to insurance and litigation. ⋯ Recent research has identified the problems and solutions, including the best way to train maternity teams to make a palpable difference. We describe simple yet evidence-based methods to improve teams and leaders.
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Sepsis is a major cause of maternal mortality and morbidity worldwide. In the UK, sepsis is now the leading cause of direct maternal deaths. ⋯ The challenge in the management of maternal sepsis is the translation of the vast knowledge gained from sequential confidential enquiries into maternal death and research findings, into clinical practice, to ensure an improvement in patient quality of care and maternal mortality and morbidity. In this chapter, I give an overview of the management of the risks of sepsis, and discuss implementation strategies that may reduce these risks.