Evidence map›Paper›PMID 27013637›Full record

ArticleBMJ quality & safety2017

Towards optimising local reviews of severe incidents in maternity care: messages from a comparison of local and external reviews.

Anjali Shah, Bryn Kemp, Susan Sellers, Lisa Hinton, Melanie O'Connor, Peter Brocklehurst, Jenny Kurinczuk, Marian Knight

Abstract read
PubMed Full text at PMC Publisher
In one paragraph

Article in BMJ quality & safety, 2017. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.

0numbers the graph read from it
0cells of the map it votes in
1citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

1 citing paper in PubMed.

  1. Article
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

8 authors.

Anjali ShahNational Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
Bryn KempNational Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
Susan SellersDepartment of Obstetrics and Gynaecology, University Hospitals Bristol NHS Trust, Bristol, UK.
Lisa HintonHealth Experiences Research Group, Department of Primary Health Care Sciences, Oxford University, Oxford, UK.
Melanie O'ConnorNational Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
Peter BrocklehurstInstitute for Women's Health, University College London, London, UK.
Jenny KurinczukNational Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
Marian KnightNational Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.

Funding

Department of Health NIHR-RP-011-032Department of Health RP-PG-0608-10038
6 · The paper itself

Abstract

backgroundDetailed local case review is commonly used as a strategy to improve care. However, recent reports have highlighted concerns over quality of local reviews in maternity care. The aim of this project was to describe the methods used for conducting local reviews of care of women with severe maternal morbidity, and to compare lessons identified for future care through external and local reviews.

methodsThirty-three anonymised clinical records from women with severe maternal morbidities were obtained, together with the report of the local review of their care. The methodology used for the local reviews was described, including specific tools used, team members involved, their disciplines, report format and whether an action plan with recommendations for audit was produced. Multidisciplinary external reviewers considered the records using a standard confidential enquiry approach. A thematic analysis of lessons learned from the two approaches was undertaken.

resultsA formal report of the local review was produced for 11/33 cases; 4 of these used root cause analysis. A further 12 local reviews consisted of a group discussion with output noted in a spreadsheet; 5 consisted of a timeline with good practice points and 5 had no formal review. Patients were involved in five local reviews; only one was multidisciplinary. Action plans were recorded in 14 local reviews; 3 of these included a recommendation to audit the proposed changes. External reviews identified additional messages for care and highlighted aspects of good care in every case, whereas only 55% (n=18) of local reviews identified good care (p<0.0005).

conclusionsThe quality of local reviews can clearly be improved. Very few of the reviews involved patients. Local reviews should be multidisciplinary, generate an action plan, and the implementation of recommendations should be audited. Improvements in local reviews may be achieved by standardised training or development of national protocols.

Indexed as

ObstetricsQuality Assurance, Health CareFemaleHumansMaternal HealthMedical AuditMedical ErrorsAudit and feedbackIncident reportingNear missObstetrics and gynecologyWomens health

Identifiers

PMID27013637
PMCPMC5502240

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.