Helps Änne, Leitao Sara, O'Byrne Laura, Greene Richard, O'Donoghue Keelin
Pregnancy Loss Research Group, The Irish Centre for Maternal and Child Health Research (INFANT), University College Cork, Cork University Maternity Hospital, 5th floor, Wilton, Cork, Ireland; National Perinatal Epidemiology Centre (NPEC), University College Cork, Cork University Maternity Hospital, 5th floor, Wilton, Cork, Ireland; Cork University Maternity Hospital, Wilton, Cork, Ireland.
Pregnancy Loss Research Group, The Irish Centre for Maternal and Child Health Research (INFANT), University College Cork, Cork University Maternity Hospital, 5th floor, Wilton, Cork, Ireland; National Perinatal Epidemiology Centre (NPEC), University College Cork, Cork University Maternity Hospital, 5th floor, Wilton, Cork, Ireland.
Midwifery. 2021 Oct;101:103049. doi: 10.1016/j.midw.2021.103049. Epub 2021 May 28.
External inquiries are carried out following adverse maternal/perinatal events, to examine the care provided and make recommendations to improve it. Clinical governance ensures that organisations promote high-quality care and are accountable for the care they provide, thus contributing to its improvement.
This study examined how Irish perinatal bereavement services and the management of perinatal deaths (including events leading up to the deaths) were affected by developments in maternity services governance as described in ten Irish enquiry reports published over 14 years (2005-18).
Two clinicians collected data from the ten enquiry reports by using a specifically designed review tool. Thematic analysis was carried out, following the steps of familiarising, coding, identifying, grouping and revising themes.
Seven main themes were identified: workforce, leadership, management of risk, work environment, hospital oversight, national documents, data collection. Eight reports noted shortcomings in staffing levels, with a workforce that was under-resourced, and at times carried excessive workloads. The absence of 24/7 midwifery-shift leaders in maternity units resulted in problems with care at times not being escalated appropriately. The absence of a widely-owned, understood strategic plan for the management of the maternity services was mentioned in the reports from 2013. Conclusions and implications for practice The National Bereavement Care Standards were published in 2016 to address deficiencies identified in the enquiry reports and to standardise perinatal bereavement care across Irish maternity units. Though the first Irish Maternity Strategy (2016-26) was published in 2016, its implementation is incomplete. Inconsistencies remain in the definition and collection of national perinatal data, as well as concerns regarding the lack of local audit activities on pregnancy outcomes. Greater focus on hospital oversight, implementation of national documents and reliable data collection is required. To be effective and initiate positive changes in clinical services, documents such as incident reviews, national strategies and national reports including inquiries, need to include realistic recommendations with clear timelines and responsibilities for implementation.
在发生孕产妇/围产期不良事件后会进行外部调查，以审查所提供的护理并提出改进建议。临床治理确保各组织促进高质量护理并对其提供的护理负责，从而有助于护理质量的提高。
本研究调查了爱尔兰围产期丧亲服务以及围产期死亡的管理（包括导致死亡的事件）是如何受到14年间（2005 - 2018年）发布的十份爱尔兰调查报告中所描述的产科服务治理发展的影响。
两名临床医生使用专门设计的审查工具从十份调查报告中收集数据。按照熟悉、编码、识别、分组和修订主题的步骤进行主题分析。
确定了七个主要主题：劳动力、领导力、风险管理、工作环境、医院监督、国家文件、数据收集。八份报告指出人员配备水平存在不足，劳动力资源不足，有时工作量过大。产科病房缺乏全天候的助产士轮班负责人，导致护理问题有时无法得到适当升级处理。2013年的报告提到缺乏一个广泛认可和理解的产科服务管理战略计划。结论及对实践的启示 2016年发布了《国家丧亲护理标准》，以解决调查报告中发现的缺陷，并使爱尔兰各产科病房的围产期丧亲护理标准化。尽管爱尔兰首个产科战略（2016 - 2026年）于2016年发布，但其实施并不完整。国家围产期数据的定义和收集仍然存在不一致之处，同时也有人担心缺乏关于妊娠结局的本地审计活动。需要更加关注医院监督、国家文件的实施以及可靠的数据收集。为了在临床服务中有效并引发积极变化，诸如事件审查、国家战略和包括调查报告在内的国家报告等文件需要包括具有明确时间表和实施责任的切实可行的建议。
