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Risk Management & Use Of Informationin
Maternity Services
Farah BabaeyHead Of Midwifery Office
February -2011
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هدف كلي :ارتقاء کیفیت خدمات در بخش زایمان
با استفاده از رويكرد حاکمیت خدمات بالینی
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نتایج استقرار حاكميت باليني در بخش زایمان
مادر مورتالیتی کاهش
نوزاد مورتالیتی کاهش
( عوارض نوزاد و مادر موربیدیتی و جسمیکاهش( روحی
نوزاد و مادر ایمنی افزایش
مددجو رضایتمندی افزایش
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مديريت خطر و ايمني بيمار
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Clinical Risk Management
A process of identification of risks which have adverse effect on the quality of care and safety of patients. The assessment and evaluation of those risks and the positive action to reduce them.
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Clinical Risk ManagementPart of clinical governanceQuality in careIdentifying risksAvoidance or diminution of riskTaking positive action to eliminate riskImproving the clinical environment
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بيمار ايمني و خطر مديريت؟ هدفی چه با و چرا
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Three Important Studies
New York StateNew York State 30,121 patients in 51 30,121 patients in 51
hospitalshospitals 1,133 (3.8%) suffered 1,133 (3.8%) suffered
‘medical error’ injury;‘medical error’ injury; 154 died154 died
New South Wales and South New South Wales and South AustraliaAustralia 14,179 patients in 26 14,179 patients in 26
hospitals hospitals 2,353 (16.6%) suffered ‘medical 2,353 (16.6%) suffered ‘medical
error’ injury;error’ injury; 115 died115 died
Greater LondonGreater London 1,014 patients in 2 hospitals1,014 patients in 2 hospitals 110 (10.8%) 110 (10.8%) suffered ‘medical suffered ‘medical
error’ injury;error’ injury; 9 died9 died
Brennan, Leape et al. Incidence of Brennan, Leape et al. Incidence of adverse events and negligence in adverse events and negligence in hospitalised patients.hospitalised patients.NEJM, 1991;324:370-6 NEJM, 1991;324:370-6
Wilson RM, et al. The quality in Wilson RM, et al. The quality in Australian healthcare studyAustralian healthcare studyMed J Aust, 1995;163:458-71Med J Aust, 1995;163:458-71
Vincent C, Neale G, Woloshynowych Vincent C, Neale G, Woloshynowych M. Adverse events in British M. Adverse events in British hospitals: a preliminary retrospective hospitals: a preliminary retrospective record review.record review.BMJ, 2001;322:517-9BMJ, 2001;322:517-9
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Risk of Fatal Outcome per Exposure
10101010101010
Nuclear Power
Railways
Scheduled AirlinesMotoring
Motorbikes & Cycles
Scuba Diving
Rock climbing
Bungee Jumping
Manned space shuttle flight
Sport parachuting
Dangerous Acceptable Risk Safe Ultra Safe
--22- - 33- - 44 - - 55- - 66- - 77 --88
Hospital Admissions
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Why IN Maternity Services ?
It is estimated that 4 million newborns die in
the neonatal period, greater than half a million
mothers die in childbirth, and 3 million stillbirths
occur annually. Data strongly suggest that most
newborn and maternal deaths, and a large
percentage of stillbirths are avoidable.
(WHO )
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روند شاخص مرگ مادردراثر عوارض بارداری و زایمان درصد هزار تولد زنده درکشور
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علل شایع مرگ مادردر ایران
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انواع تاخیر در موارد مرگ مادر
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محل حسب بر شده فوت مادران درصدفوت
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مقطع حسب بر شده فوت مادران درصدفوت
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Eenhancing SafetyIn
Maternity Services Best possible outcomes for mother,
baby and family
Best possible, high quality Maternity Services for all
(NHS)
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Enhancing Safety In Maternity Services
Safe Maternity Services
WomenStaff
BabiesCommissioners
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Trigger List
Maternal death
Neonatal death
Stillbirth
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Trigger List /Mother Third/fourth degree
tearsRuptured uterusMaternal admission
to ICUInjury during
operative procedure
Return to theatreRetained foreign
bodies
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Trigger List /Newborn Shoulder dystociaBirth trauma to
babyLow Apgar scores
(<7 at 5mins)Low pH (7.15)Cord accidentTerm baby
(>37weeks) admitted to NICU
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پيشگيرانه رويكردProactive Approach
بارداري- حين و قبل الف بارداري قبل مشاوره بارداي دوران در خطر پر مادران غربالگری پرخطر مادران ارجاع نظام واستقرار ترسيم مادران گروه بستري جهت فيزيكي فضاي گرفتن نظر در
بارداري حين بستري نيازمند پرخطر باردار در بيمارستان مجاورت در مادران اسكان امكان برقراري
العبور صعب مناطق
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پيشگيرانه رويكردProactive Approach
که وزایمان لیبر بخش در رایج خطاهای وقایع وتبین بندی طبقهاست آمیز مخاطره نوزاد و مادر برای
( و خطر مديريت استقرار نوزاد مادرو ایمنی شاخص تدوین ) مددجو ايمني فرهنگ
رایج احتمالی ازخطاهای پیشگیری برای دستورالعمل تدوین زمينه اين در الورود جدید افراد آموزش نمودن الزامی بعد دردوران خطر عالئم مورد در خانواده مادرو به آموزش
سزارين يا زايمان در خصوصا زایمان از پس های مراقبت انجام جهت العمل دستور
مشكل 24 سزارين يا طبيعي زايمان كه مادران بوي ژه اول ساعتاند داشته
بروز احتمال به توجه با ترخیص از بعد هایریسک مادر پیگریتا زایمان 42مشکالت از روزبعد
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Reactive Approach
علل مادر بررسي مرگ کمیته در مرگ اي ريشهدهی) ثبت،گزارش سیستم موربيديتي و مورتاليتي
خطا ( تحلیل و بازخوانی ( بازخوانی دهی ،گزارش ثبت سیستم نوزاد مرگ کمیته
خطا تحلیل و و ،موربیدیتی مادری مرگ موارد از گیری Nearدرس
Miss Learn & Share
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WHO Surgical Safety Checklist for maternity cases only
SIGN IN (to be said out loud after the
arrival of the woman and the midwife)
TIME OUT (to be said out loud before skin
incision)
SIGN OUT (to be said out loud before the
woman leaves theatre)
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Safe childbirth checklist gathering the evidence
for1. the major causes of morbidity and
mortality for newborns and mothers2.interventions that have been shown to
improve morbidity and mortality3.action steps that if missed lead to
increased morbidity and mortality
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System Faults
Catalyst Events
Big Fatal Error
Loss of awarenes
s
Operator Errors
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استفاده از اطالعات
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USE OF INFORMATION
و مادر مورتاليتي هاي شاخصنوزادان
IT STEERING GROUP
رضايتمندي سنجش نتايج
شخصي ميل با رضايت هاي بررسي نتايج
نوزادان و مادران موربيديتي هاي شاخص
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استفاده از اطالعات
تحلیل ،مرگ تجزیه مادر مرگ های کمیته مستنداتنوزاد
مددجودر رضایتمندی سنجش نتایج اخالق بررسی کمیتهبيمارستاني پزشکی متعالی ارزشهای و
ترویج کمیته در خدمت دهندگان ارائه عملکرد بررسیطبیعی زایمان
و) . ........( ،موربيديتي مورتاليتي