Conditions triggering local incident reviews in UK hospital maternity units: A national survey

OBJECTIVES: In countries, such as the UK, where maternal deaths are rare, reviews of other severe complications of pregnancy and the puerperium can provide an additional perspective to help learn lessons to improve future care. The objective of this survey was to identify the types of incidents which triggered local reviews in the UK, in order to inform national safety reporting guidance. DESIGN: A national descriptive survey. SETTING: UK. PARTICIPANTS: Consultant-led maternity units. MAIN OUTCOME MEASURE: Seventy-one per cent of maternity units provided an incident review trigger list. The conditions included were classified by two assessors. Incidents that were listed by at least 5% of maternity units were reported and compared with incidents recommended for review by the Royal College of Obstetricians and Gynaecologists (RCOG). RESULTS: The conditions covered were highly variable, although those recommended by the RCOG were most highly represented. The most commonly listed conditions that had not been recommended for review by the RCOG included inadequate staffing levels (70%), cardiac arrest (69%) and maternal sepsis (64%). CONCLUSIONS: Substantial variation exists in the types of incident listed for review by maternity units in the UK. Importantly, some units are not reviewing cases of severe infective complications even though this is a current major concern. Future guidance concerning local serious incident review processes should include how the list of conditions triggering a review should be managed in the light of changing clinical and safety priorities.