Perinatal Adverse Event Reviews

National Adverse Event Review Framework

The national Healthcare Improvement Scotland (HIS) Learning From Adverse Event Review National Framework for Scotland aims to ensure any staff involved are supported in a consistent manner, events are reviewed in a consistent way, and learning is captured and shared locally and nationally to improve the quality of services.

New Maternity and Neonatal (perinatal) Adverse Event Review Process for Scotland Guidance

The new Perinatal Adverse Event Review Guidance aims to bring perinatal context and consistency as an addendum to the national framework.

Events subject to Perinatal Mortality Review should also follow national PMRT guidance.

The new guidance was launched as part of a webinar hosted by Maternal & Child Quality Improvement Collaborative (MCQIC) on 15th September 2021.  You can watch the full MCQIC Perinatal Mortality Review Tool webinar here.

Dr Dr Corinne Love and Dr Edile Murdoch launch the new Perinatal Adverse Event Review Guidance at 46:40 in the video.

Supporting the New Perinatal Guidance: The SPN

The SPN has committed to supporting the perinatal community to implement the new guidance, in collaboration with strategic partners such as NES and HIS – including the HIS Adverse Events Network and the Maternity and Children Quality Improvement Collaborative (MCQIC), which is part of the Scottish Patient Safety Programme (SPSP).

The SPN will:

• Develop a ‘safe space’ learning forum on MS Teams and a corresponding ‘collaboration space’
• Facilitate regular case review events at which Boards can present, discuss and share learning (quarterly or 6-monthly)
• Facilitate tailored learning opportunities, as requested, following particular incidents or events.
• Develop a process to ‘Buddy-up’ smaller with larger Boards for peer support and to add structure to request for external reviewers.
• Establish a perinatal SAERs working group through which to support implementation of the framework, provide support, and share learning and best practice.

Supporting the New Perinatal Guidance: Sharing Learning – Joint Commission for Safety, Openness and Learning (NES and HIS) 

Until April of 2022, following an SAER in any service, colleagues could access a generic Learning Summary Template and Guidance at an Online Community of Practice on Knowledge Network. Following a review process, this will be replaced with an improved approach developed through a Joint Commission for Openness and Learning between Healthcare Improvement Scotland (HIS) & NHS Education Scotland (NES). More information on this will follow soon.

Involving patients and Family

The ECHO community of practice for adverse events Project ECHO will be assisting the NES/HIS joint commission for safety openness and learning to explore this further in a learning community of practice with a specific focus on what difference involving patients and family makes to the quality of the review and the learning gained. It can be accessed at highlandhospice.org/adverse-events-echo-involving-patients-and-carers.

Underpinning research into what ‘good’ patient and family involvement in healthcare adverse event reviews may involve was published by the team in the BMJ in 2022.

Supporting the New Perinatal Guidance: Training – NHS Education for Scotland (NES)

In addition to bespoke staff training provided by NHS Boards, NHS Education for Scotland provides a suite of three workshops designed to provide NHS staff involved in investigation work and those in leadership/management positions with the skills required.  These include training on learning from safety incidents in complex care environments, building a safety culture and other associated areas. NES can provide the package of these workshops in a combined bespoke half-day session. Further details are available on the NES website.

NES also has:

• an Enhanced Significant (learning) Event Analysis (SEA) e-module
• entry-level Human Factors e-modules
• a Duty of candour e-module (which includes a ‘train the trainers’ component)
• Online Compassionate Communication Skills Training on including patients and families in adverse event reviews. Training is based on the APICCTHS model and delegates progress through the training as a group. Contact NES at nes.personcentredcare@nhs.scot for more information or to join a cohort.

In addition to training, it is important that appropriate measures are in place to support the wellbeing of staff during and following involvement in an adverse event review process.