Pregnancy Loss Research Group, The Irish Centre for Maternal and Child Health Research (INFANT), University College Cork.
National Perinatal Epidemiology Centre (NPEC), University College Cork.
Ir Med J. 2020 Feb 13;113(2):21.
Aims External inquiries are carried out following specific adverse events in healthcare, many in maternity care; to identify issues and make recommendations to improve standards of care. Methods Ten publically-available national inquiry reports published between 2005-2018 relating to pregnancy loss services, were reviewed by 2 clinicians, separately, examining the content and recommendations from each report. Results A total of 258 recommendations were made in 9 reports (90%). Five inquiries (50%) clearly stated that affected families were involved and four (40%) involved affected clinical staff. In 9 reports (90%) recommendations included: increase workforce staffing and/or training, strengthen clinical governance, enhance adverse incident management and comprehensive data collection e.g. maternity outcomes. Only two inquiry reports (20%) stated that feedback was sought from key stakeholders prior to publication. Conclusion A collaborative and standardised inquiry process involving and supporting all persons affected as well as key stakeholders would ensure that all relevant issues are identified, recommendations are implemented and essential lessons are learned.
目的
在医疗保健领域，特别是在妇产科，会针对特定的不良事件进行外部调查，以确定问题并提出建议，从而提高护理标准。
方法
对 2005 年至 2018 年间发布的 10 份公开的国家调查报告进行了审查，由 2 名临床医生分别进行，从每份报告的内容和建议方面进行审查。
结果
在 9 份报告（90%）中共提出了 258 条建议。5 项调查（50%）明确表示涉及受影响的家庭，4 项（40%）涉及受影响的临床工作人员。在 9 份报告（90%）中提出的建议包括：增加工作人员配备和/或培训、加强临床治理、加强不良事件管理和全面数据收集，例如产妇结局。只有 2 份调查报告（20%）表示在发布前曾向主要利益相关者征求意见。
结论
一个涉及和支持所有受影响人员以及主要利益相关者的协作和标准化的调查过程，将确保确定所有相关问题、实施建议和吸取必要的经验教训。
