Search

Anaesthesia should be represented on all committees responsible for maternity services (e.g. the maternity services liaison committee, delivery suite forum, obstetric multidisciplinary guidelines committee, obstetric risk management committee).^22,25.59

Hospitals should have systems in place to facilitate multidisciplinary morbidity and mortality meetings.^25,151

Anaesthetists should be an integral part of locally developed networks looking at obstetric services.²⁵

When members of the healthcare team are involved in a critical incident, they can be profoundly affected. A team debriefing should take place immediately after a significant critical incident. The lead clinician should review the clinical commitments of the staff concerned promptly. Further practical and psychological support may be necessary to assist individuals to recover from a traumatic event.²⁵

There should be local governance measures in place to respond to serious incidents. These measures should protect patients and ensure that trained safety leads carry out robust investigations. When an incident occurs, it should be reported to all relevant bodies within and beyond the hospital. A system of peer review or external evaluation of serious incident reports should be in...

An anaesthetist should be involved in all case reviews where the case includes anaesthetic input.²

The lead obstetric anaesthetist should audit and monitor the duty anaesthetist’s workload to ensure that there is sufficient provision within the unit. Senior management should be made aware of any deficiencies found.

There should be effective governance systems and processes in place to assess, monitor and improve the quality and safety of services with particular reference to local guidelines, reviews of adverse events, and record keeping.^23,25

There should be organisational support provided to facilitate data collection and analysis in obstetric anaesthesia to assist with quality improvement and benchmarking.^25,154

All cases of maternal death, significant permanent neurological deficit, failed intubation or awareness during general anaesthesia should undergo case review, with learning from this shared locally and/or nationally (by reporting to MBRRACE).²⁹