Enhancing patient safety: insights from Gateshead Health’s maternity unit

The importance of patient safety within hospitals cannot be overstated, as it plays a pivotal role in fostering trust, improving the quality of care, and ultimately saving lives.

Marissa Jones, the Quality, Risk, and Safety Midwife in the maternity unit at Gateshead Health, provides insight into how we ensure safety within our maternity unit.

Marissa Jones, the Quality, Risk, and Safety Midwife in the Gateshead Health maternity unit
Marissa Jones, the Quality, Risk, and Safety Midwife

The maternity unit holds a “safety huddle” twice daily. This nationally recognised practice occurs every morning and evening on Delivery Suite. During the safety huddle, representatives from various areas within the maternity unit, including the antenatal and postnatal wards, the pregnancy assessment unit, the special care baby unit, members of the anaesthetic team, operating department practitioners, and on-call doctors, come together. This time is used to discuss daily expectations, ensure appropriate and safe staffing in every area, and address any potential complex scenarios or unusual maternity cases.

This multidisciplinary approach keeps all team members informed and involved in each area’s activities. This allows everyone to plan their day accordingly. These updates, conducted at the start of the day and night shifts, help manage unexpected events, such as last-minute staff sickness, by facilitating quick communication and coordination for additional support.

Recently, the “Tea Trolley” initiative was launched. With a tea set acquired from a charity shop, the trolley is loaded with tea,biscuits, and information. The practice development and quality,safety and risk teams visit areas within maternity with the trolley to engage staff, inviting them to take a short break, have tea, and learn about new equipment, procedures or hear the most recent safety messages. This approach has been practical in getting staff to actively engage with new information instead of merely posting information on a wall or discussing it in safety huddles where not all staff are present.

Maternity unit staff with the tea trolley.
Maternity unit staff with the tea trolley

Additionally, a weekly risk quality and safety meeting with midwives, matrons, consultants, registrars, and junior doctors is held to identify incidents, learn from them, and ensure continuous patient care and safety improvement. This meeting covers a wide range of incidents, from power failures to unexpected admissions to the special care baby unit, enabling the team to identify trends and take proactive measures to enhance patient safety.

When an incident is identified, the risk quality and safety team investigate it. For example, if an incident occurs in the pregnancy assessment unit, the incident is discussed at the meeting and looked at by the team.

An example of learning from an incident involves a case where staff needed to care for a patient in the accident and emergency department. Staff were frequently travelling back and forth to get equipment. As a result, a “grab bag” with all necessary equipment was prepared and placed in the labour ward for easy access during maternity cases in other parts of the hospital. Another incident involved a computer in another hospital department where an expecting mother was being treated. This area did not have access to the maternity records system, which was resolved by uploading the necessary program and streamlining the process for staff.

Additionally, to improve the disposal of sharps, changes were made to the location of sharps boxes to make them more accessible.

Safety messages are regularly emailed to all maternity staff members to share learning from incidents with the broader team. These messages are also discussed in monthly multidisciplinary safe care meetings and uploaded to the staff learning library.

Ensuring all staff members know the latest safety updates is crucial, especially for those who may have been on leave or are new to the unit.

Maternity unit staff at a patient safety meeting.
Maternity unit staff at a patient safety meeting

Another initiative is the patient safety placements for final-year student midwives, which began in 2021. This program, developed in collaboration with regional education systems, aims to promote a safety culture and increase student capacity. In a pilot study, students spent 2 weeks with the patient safety team, investigating incidents and interacting with stakeholders. They presented their findings, highlighting areas for improvement and best practices. This experience exposes them to real-world patient safety issues and helps build a positive safety culture. It is about learning from incidents without blame and understanding how human factors and systems contribute to outcomes.

A poster about patient safety placement for final year student midwives.
Patient safety placement for final year student midwives, poster.

Feedback from students has been overwhelmingly positive. Initially nervous about participating in investigations, they discovered that the process is about understanding situations and improving systems rather than a blame culture. This hands-on experience is invaluable, fostering a deeper understanding of patient safety and preparing them for future roles.

In summary, Gateshead Health is improving training, engaging staff, and building a robust safety culture within the trust through initiatives like the Tea Trolley and patient safety placements.