Maternity Healthcare Worker Perspectives of Severe Acute Maternal Morbidity Recording, Reporting and Case Review in Queensland, Australia.

backgroundSystematic, multi-disciplinary review of Severe Acute Maternal Morbidity (SAMM) can improve maternal outcomes. Routinely collected data, collated into the Queensland SAMM Dashboard, may facilitate local case review. We wanted to understand how SAMMs are reviewed locally and how centrally collated data supports review processes.

aimsThe purpose of this survey was to assess local SAMM recording and review practices in Queensland. MATERIALS AND

methodsA cross-sectional online survey, using multiple choice and free-text response formats, sampled multi-disciplinary health care workers (HCW) involved in SAMM review in Queensland public maternity units. Responses were analysed for content, with thematic analysis performed on free-text comments.

resultsTwenty HCW responded from a mix of tertiary, regional and rural maternity facilities. HCW responses identified a lack of clarity around the terms 'maternal morbidity', 'SAMM' and 'Near-Miss'. HCW reported various approaches for recording and reviewing SAMM. The commonest structures were Root Cause Analysis and Human Error and Patient Safety incident analysis. Reviews commonly involved: patient safety teams (50%); staff involved in the case (45%); independent/external reviewers (40%) and hospital management (40%). Few responses (10%) indicated consumers were involved. 30%-80% reviewed the ACSQHC defined SAMM, 70% Near-Miss cases and up to 70% reviewed other severe maternal morbidity indicators. 20% of HCW stated lessons learned during reviews were shared with other hospitals.

conclusionsIn Queensland, we have found variability in: HCW understanding of SAMM definitions, how cases are recorded, reviewed and improvements facilitated. A standardised approach to SAMM review and collaboration to share lessons learned may benefit maternity care.