Displaying 1-10 letters out of 65 published
Measuring the true impact of an electronic physiological surveillance system (EPSS)Dear Sir, We read with interest the article by Schmidt et al. We applaud the authors for undertaking this large and complex study and for highlighting the great potential of newer technologies to improve patient care. We hoped the authors could clarify some key issues. Firstly only one year's mortality data are used as a baseline comparator. Mortality fluctuates by year as this paper highlights, and can be affected by a large number of factors including how it is expressed (1). It is possible that the year chosen may have been an outlier that triggered the Trusts to actively invest in measures including EPSS. We would therefore be grateful if the authors could provide additional data on mortality in the years prior to the intervention. Were other strategies employed alongside EPSS? For example we understand University Hospital Coventry also called in Dr Foster Intelligence in 2007 to restructure practice (2). As the paper uses only a historical comparator it is possible that a proportion of the improvement reflects the general national improvement in hospital mortality seen over the last decade (3). Do the authors have any data comparing their improvements with other Trusts of a similar size, case-mix, and similarly average HSMR (4)? Interventions in healthcare are rarely without some adverse effects and as such we would be interested in any data collected on the potential negative aspects. These would include consequences of the increased workload for junior doctors and financial effect cost. Establishing that these were relatively minor would be very reassuring for other Trusts considering similar strategies. While we agree that randomised controlled trials are complex, we suggest there is a strong rationale for them to disaggregate the benefit of EPSS from many confounding factors, and to inform clear health economic analysis. Yours sincerely, Dominick Shaw, John Blakey and Jamie Rylance 1 http://www.nejm.org/doi/full/10.1056/NEJMsa1006396#t=articleMethods 2 http://drfosterintelligence.co.uk/wp-content/uploads/2013/02/University-Hospitals-Coventry-Warwickshire-NHS-Trust-case-study.pdf 3 http://www.biomedcentral.com/1472-6963/13/216 4 http://drfosterintelligence.co.uk/wp-content/uploads/2011/11/Hospital_Guide_2011.pdf
Conflict of Interest:
WHO Safer Surgery Checklist not Immune to Human Errors
We wish to congratulate Russ SJ et al. (1) for their excellent survey investigating patients' views of the WHO safer surgery checklist.
The authors point out that the UK wide implementation of the checklist has encountered some difficulties. Specifically, barriers including checklist fatigue and difficulties in assembling the theatre team are mentioned. Whilst we certainly agree with this, we wish to amend the authors' catalogue of concerns by sharing our experience at Queen Alexandra Hospital (QAH).
At QAH we operate a modified WHO safer surgery checklist to suit local practice. The checklist is applied to every patient passing through the theatre complex. During a routine audit we identified how an apparently minor communication error fundamentally undermined the checklist's safety function and placed our patients at risk.
Our venous thromboembolism (VTE) prophylaxis checkpoint reads 'VTE prophylaxis considered?'. In practice however, this question is frequently altered to 'Flowtron's on?' (Flowtron refers to the intermittent pneumatic calf compression devices (IPCCD) used at QAH). The multiple meanings of the word 'on' (either interpreted as 'on the patient' or 'switched on') introduced ambiguity and a communication error. This incorrect use of the checklist resulted in multiple patients having IPCCDs applied to their calfs, yet the devices were never switched on and our patients were placed at risk.
Our experience illustrates two important communication errors that may undermine the checklist's safety function. Firstly, accurate and unambiguous wording of each component of the checklist is essential. Words with homonymous meanings should be avoided where possible. Secondly, each checklist question must be verbalised accurately during the patient check to avoid introducing errors.
The original WHO safer surgery checklist (2009) (2) limits such potential error, as most questions are yes/no answerable. Any local checklist modifications should aim to maintain this format. Introducing words with homonymous meanings may lead to communication errors; undermine the checklist's safety function and place patients at risk.
1. BMJ Qual Saf. 2014 Jul 18. The WHO surgical safety checklist: survey of patients' views. Russ SJ, Rout S, Caris J, Moorthy K, Mayer E, Darzi A, Sevdalis N, Vincent C.
2. http://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdf?ua=1 (accessed 18/08/14)
Conflict of Interest:
'Between the flags': implementing a rapid response system at scale - A reply
The authors (1) have raised a very important issue relating to recognition and management of a deteriorating patient. Over the years, cases have been reported where outcome may have been better if deterioration was recognized in time. Once recognized, an urgent response by a qualified team could instigate immediate investigations and management as warranted, possibly averting a poor outcome.
Code blue calls or cardiac arrest teams (2) were first introduced in 1970, with the motive of initiating an urgent response to a deteriorating patient. By definition, activation of this system occurred after an arrest had occurred, so patient had no recordable pulse, blood pressure, respiration and did not respond to noxious stimuli.
However, more gains were to be made by initiating this response before the patient had reached a terminal stage. Based on research showing that cardiac arrest usually follows a series of events, attempts were made to identify these events so as to preempt an arrest before it actually occurred. Medical emergency teams (MET) were a culmination of these efforts.
MET responses, introduced circa 2000 include a critical care registrar and nurse, among others. Any clinician caring for a deteriorating patient is encouraged to activate the response though a rapid response system and can expect help within minutes. Whilst the concept of MET response is similar to that of cardiac arrest teams, a fundamental difference is in the timing of initiating the response.
However, the MET response is also activated after a level of deterioration has occurred. The quest continued to find alarm signs or signals that indicate deterioration is likely to occur. Once again, the presumption is that an earlier response, before deterioration has occurred, should result in a better outcome.
Analysis of hospital admissions suggests an adverse outcome is likely in about 10% of admitted patients (3). Improving the outcome further, particularly for these 10%, has triggered a nationally coordinated approach that is being overseen by the Australian Commission on Safety and Quality in Health Care (ACSQHC).
A new paradigm as suggested by Jones et al (4) would be required to drive this further improvement. The focus is now on early detection and prediction of clinical deterioration, so urgent help can be sought even before the situation actually worsens. Eight essential elements have been identified and compiled into a package that is the effort of ACSQHC. Despite differences, it was encouraging that this consensus statement was ratified by all state health ministers in Australia (5). The package, widely distributed throughout Australian hospitals, is hoped to improve outcomes by encouraging early detection of deterioration, and calling for help early.
These strategies, in addition to the "swimming between the flags" observation chart and rapid response systems include many other initiatives with focus on education as one of the essential elements. Different educational programs and packages such as COMPASS and DETECT (5) have been developed in Australia specifically to improve practice regarding the recognition and response to clinical deterioration amongst all staff.
1. Hughes C, Pain C, Braithwaite J, Hillman K. 'Between the flags': implementing a rapid response system at scale. BMJ Qual Saf 2014;23:714- 717
2. McGrath RB. In-hospital cardiopulmonary resuscitation -- after a quarter of a century. Ann Emerg Med 1987; 16: 1365-1368.
3. Runciman W and Moller J. Iatrogenic Injury in Australia, A Report prepared by the Australian Patient Safety Foundation for the National Health Priorities and Quality Branch of the Department of Health and Aged Care of the Commonwealth of Australia (2001) available from: http://www.apsf.net.au/dbfiles/Iatrogenic_Injury.pdf (accessed September 2014)
4. Jones AD, Dunbar NJ and Bellomo R. Clinical deterioration in hospital inpatients: the need for another paradigm shift. Med J Aust 2012; 196 (2): 97-100
5. Australian Commission on Safety and Quality in Health Care. National consensus statement: essential elements for recognising and responding to clinical deterioration. Sydney: ACSQHC, 2010. Available from: http://www.safetyandquality.gov.au/wp-content/uploads/2012/02/Nat- Consensus-Statement-PDF-Complete-Guide.pdf (accessed Sept 2014)
Conflict of Interest:
SURGERY AND CHECKLISTS: WHAT A PILOT WOULD LIKE TO KNOW
Dear Editor, we would like to congratulate Russ et al. on their paper on the patients' views of surgical checklists (SC). In their elegant work, the above authors underlined that assessing the fidelity of the SC remains a challenge, but demonstrated a high level of patient support for use of checklists. They found that patients were surprised that SC was only a recent introduction to surgical care. Moreover, the authors stressed that the majority of patients agreed that they would like the SC to be used if they were having an operation. In our experience, we confirm that the value of SC does not lie in the so- called Hawthorne effect, but in changing (improving!) the mental model. As also documented in the field of aviation, most accidents tend to involve non-technical skills (NTS) such as communications, leadership, conflict, and flawed decision-making. The relationship between NTS and human error has been extensively demonstrated. In Aviation it is mandatory for pilots to read a checklist for every single phase of flight. Of course they know the checklists by heart, but what if....you are stressed, the last leg of the day, distracted, with family problems? Of course it may be that you don't need any checklist, but will you risk it? Will you risk to take off from Toronto under snow knowing that pilots didn't read any checklist because they know procedures by heart and because statistics say it doesn't matter, and results are the same..?
We would like conclude that one of the effective barriers to error is the surgery safety checklist and, believe it or not, we are sure that pilots if going under surgery they would like to know that surgeon uses appropriate checklists that day!
____________________________________________________________ Fabrizio Dal Moro is an Assistant Professor at the University of Padova, expert on NTS.
Gianluigi Zanovello and Fabio Cassan are airline pilots in Italy: Zanovello is a former "Frecce Tricolori" (italian acrobatic team) leader; Cassan was fighter squadron commander (51' Stormo Aeronautica Militare Italiana).
They teach at Practice simulation center in the medicine University of Verona - Italy. There, surgeons can practice exactly like the pilots and run-through not only the anatomy before the real procedure. There is something else: get familiar with NTS and understand that communication, decision making, teamwork, situation awareness are important as the professional, and technical.
Conflict of Interest:
Evidence-based E-Health Policy - Vitally Important but not a New Call
The editorial from Sheikh, Atun, and Bates is welcome in flagging up a key issue in the context of England and the US. However, it is not a new issue, and it is disappointing that they do not acknowledge prior and concurrent work.
The need for, and challenges impeding, evaluation of health information systems have been flagged up much earlier, e.g. Rigby 1999; 2001. Both the European Federation for Medical Informatics (EFMI) and the International Medical Informatics Association (IMIA) have groups which have followed up this theme. Ammenwerth instigated a European workshop which inspired a significant work programme (Ammenwerth et al, 2004), and led to production of reporting standards adopted by the EQUATOR network (Talmon et al, 2009)and guidelines (Nyk?nen et al, 2011) which have been fully elaborated (Brender et al, 2013).
The specific dual challenges behind the editorial by Sheikh, Atun and Bates are the penchant for politicians to decree policy outside their technical knowledge in order to appear progressive, and the generic need for evidence-based policy in health informatics. This latter too has recently been addressed - generically by a dedicated edition of the IMIA Year Book (S?rousi et al, 2013) which included a summary of the concerted actions of a decade (Rigby et al, 2013); and in the context of developing countries by WHO (2011) and through a joint WHO-IMIA Programme (IMIA, 2012).
Moving to evidence-based health informatics policy is vital for effectiveness, efficiency, safety, and enhanced health care delivery and outcomes. Such an approach faces challenges as it cuts across the perceived autonomy of politicians, and the worrying scant regard for a scientific evidence base of some sectors of the supplier industry, while evaluation to produce the evidence continually faces impediments as described. It is therefore vitally important that all innovators and activists work collaboratively to progress the issues.
Rigby M (1999) Health Informatics as a Tool to Improve Quality in Non -acute Care - New Opportunities and a Matching Need for a New Evaluation Paradigm; International Journal of Medical Informatics, 56, 1999, 141-150.
Rigby M (2001.)Evaluation: 16 Powerful Reasons Why Not to Do It - And 6 Over-Riding Imperatives; in Patel V, Rogers R, Haux R (eds.): Medinfo 2001: Proceedings of the 10th. World Congress on Medical Informatics, IOS Press, Amsterdam, 2001, 1198-1202.
Ammenwerth E et al (2004). Visions and strategies to improve evaluation of health information systems: Reflections and lessons based on the HIS-EVAL workshop in Innsbruck. International Journal of Medical Informatics, 2004 Jun 30; 73(6):479-91.
Talmon J. et al (2009. STARE-HI - Statement on Reporting of Evaluation Studies in Health Informatics; International Journal of Medical Informatics; 78 2009, 1, 1-9.
Nyk?nen P. (2011). Guideline for good evaluation practice in health informatics (GEP-HI); International Journal of Medical Informatics, 80, 815-827, 2011.
Brender J (2013). STARE-HI - Statement on Reporting of Evaluation Studies in Health Informatics: explanation and elaboration. Applied Clinical Informatics, 2013; 4: 331-358.
S?rousi B, Jaulent M-C, Lehmann CU (eds.) (2013). Evidence-based Health Informatics - IMIA Yearbook of Medical Informatics 2013; 34-46, Schattauer, Stuttgart, 2013.
Rigby M. et al (2013). Evidence Based Health Informatics: 10 Years of Efforts to Promote the Principle - Joint Contribution of IMIA WG EVAL and EFMI WG EVAL; in S?rousi B, Jaulent M-C, Lehmann CU. Evidence-based Health Informatics - IMIA Yearbook of Medical Informatics 2013; 34-46, Schattauer, Stuttgart, 2013.
WHO(2011)Call to Action on Global eHealth Evaluation - Consensus Statement of the WHO Global eHealth Evaluation Meeting, Bellagio, September 2011; available from http://www.healthunbound.org/content/call- action-global-ehealth-evaluation
IMIA(2012). http://www.imia-medinfo.org/new2/GA/2012beijing/1210GA- beijing-president-WHO.pdf
Conflict of Interest:
MR is retired but undertakes periodic paid and pro bono activities in health information, health policy, and related subjects.
Paperlite patient record, are we ready.
Stephanie et al has produced some very interesting observations about the impact of electronic medical records on patient-doctor communication. Recent investigations into the social care system in the light of child abuse enquiries depicted that professionals spend far too much time on making records rather than face to face meetings with families and children. More trusts in the NHS are adapting paper light patient record to improve efficiency and patient care. However, we conducted an audit in a medium secure unit in Manchester to evaluate the efficiency of electronic system and staff ability to access important clinical documents. The results showed that time spent to find these documents was significantly more on electronic record than the paper record which raises questions about the efficiency of electronic patients record.
Conflict of Interest:
Identifying system failures by incident reporting systems
With respect to the scientific article of Franklin et al. (BMJ Qual Saf 2014;0:1-8.doi:10.1136/bmjqs-2013-002572) I would like to address two further issues concerning the learning and reporting system in general as well as defense strategies in order to prevent errors in administration of intrathecal chemotherapy.
The amount of nine million incident reports in NHS is very impressive when compared to other reporting systems within European countries. NHS- reports over a period of 11 years implicates that more than 2.000 incidents have to be sent per day by healthcare professionals to the National Reporting and Learnings System (NRLS). According to published data (1) for England and Wales more than 153.000 out of 1.45 million incidents of the type "medication" were reported from Oct 2012 to Sep 2013. Severe harm or deaths were scored in 10.781 cases (0.7% per year). Errors in administration of intrathecal chemotherapy have been reported in 38 times over a decade within NHS. Compared to the German Medicine (2) (between 1995 to 2005 528 suspected adverse concerning vinca alkaloids) or the European Medicine Agency (approximately 350 documented cases), the number of reported events seems low within NHS. Nevertheless, reporting of patient safety incidents is a subjective and voluntarily exercise and on a very high level within NHS.
In many other European countries, homogenous reporting and learning system are lacking so far. In Austria for example, a NLRS is implemented and accessible for the public (3), whereas hospitals run various reporting and learning systems without national coordination and evaluation. Within four years of being online, in total 344 incidents were reported (4 reports per week) to the NLRS and thereof, 21% were scored implicating therapeutic harm.
NHS is in a leading role concerning NRLS and the level of patient safety culture with respect of reporting events as well as their open- minded way in presenting statistics to the public is unique. Concerning the data pool, NHS could support others in the development of guidelines and patient safety practices in order to overcome the most prominent hazards.
The authors presented a comprehensive list of defense strategies to prevent vinca alkaloids errors. Furthermore, we suggest, in line with the Evidence-Based Practice guideline (4), team trainings and in analogy to the WHO-Surgical Safety Checklist a team-time-out before administration of high-risk medication. Author: Name:Dr. Gerald Sendlhofer Email:firstname.lastname@example.org Title/position: 1) Head 2) Scientific co-worker Affiliations: 1) Department of Quality and Risk Management, University Hospital Graz, Graz, Styria, Austria 2) Division of Plastic, Aesthetic and Reconstructive Surgery, Medical University Graz, Styria, Austria
(1) http://www.nrls.npsa.nhs.uk/resources/collections/quarterly-data- summaries/?entryid45=135253 (accessed 7 May 2014)
(2) http://www.akdae.de/Arzneimittelsicherheit/Bekanntgaben/Archiv/2005/791_20050603.html (accessed 7 May 2014)
(3) https://www.cirsmedical.ch/austria/m_files/cirs.php?seitennr=cpFBeri (accessed 7 May 2014)
(4) Schulmeister L. Preventing vincristine administration errors: does evidence support minibag infusions? dOI: 10.1188/06.CJON.271-273
Conflict of Interest:
Adaptation in French oncology practice guidelines to patients: patient versions and patient involvement in the development process of guidelines
While Clinical Practice Guidelines (CPGs) have gained momentum to inform evidence-based practices, less investment has been made to use CPGs to support evidence-informed patient choice. The qualitative study by van der Weijden et al. shows a consensual vision of the need for and benefice of adapting CPGs into relevant patient versions to integrate patients' preferences in clinical decision-making. While we agree with the authors' conclusions and the suggested so-called generic strategy in principle, we would like to comment the proposed approach from the French perspective of CPG development and shared decision-making (SDM). Doing so, we respond to a major limitation stressed by Weijden et al. stemming from the fact that the results reflect merely an anglo-saxon perspective. Examination of non-adherence to practice guidelines of the French oncology guidelines program "Standards, Options, Recommendations" (SOR) established in 1993 by the National French Federation of Comprehensive Cancer Centres,?1? revealed that diverging patient values and preferences may hamper guideline adherence. This observation has led to two developments we would like to share here: the development of patient versions of SOR CPGs, and cancer patients' involvement in the development process of SOR CPGs.
To improve patients' involvement in decision-making, participants interviewed by the authors suggested translating CPG reports into lay terminology useful to professionals and patients. Such an approach has been implemented within the SOR program since 1999. It is based on an interdisciplinary working group (clinicians, methodologists, psychologists, linguist, anthropologist) and a triangulation of methods to involve cancer patients, combining focus groups, semi-structured interviews and postal surveys. We translated the SOR CPGs into patient versions in more than twenty cancer sites. An innovative linguistic approach was used to ensure that the information provided is adapted to patients' health literacy. A list of generic questions that patients may ask to health professionals was developed to support patient-centered communication during the medical encounter and encourage SDM,?2?. As was pointed out by Weijden et al., patient involvement in the development of SOR patient versions let us to the awareness that SOR CPGs did not adequately incorporate patient preferences, in particular the presentation of treatment options, their benefits and risks. Consequently, we set up in 2003 a process to involve cancer patients in the development of these guidelines,?3?. Our approach consisted in a cancer patient panel reviewing the guideline draft and feeding back their comments and recommendations to the guideline panel. Our approach allowed the patient group to formulate a list of key recommendations from their perspective to be addressed in the final guideline, and to point out situations most appropriate for SDM. Patients stressed the importance of improved communication and information to facilitate patient participation in the decision-making process.
Based on our experience, we hypothesize that CPGs can be adapted to facilitate the integration of patients' preferences in clinical decision- making. The French experience suggests that the consensual 'generic' strategy proposed by the authors is applicable beyond the anglo-saxon context of their study and provide a practical example of how the proposed approaches could be translated within existing guideline programs. Recent French institutional initiatives highlight a growing awareness of the need to improve connection between CPGs, patient decision aids and SDM,?4-5?.
Developing and updating high quality CPGs and patient decision support tools require substantial time, expertise and resources. We support the author's view that it is preferable to adapt existing CPGs rather than developing new patient decision support tools. Such approaches may foster the integration of research evidence and individual preferences in health care decisions, avoid duplication of effort and enhance efficiency. Further research is needed to assess the impact on clinical practice of such approaches.
1. Fervers B, Hardy J, Philip T. ? Standards, Options and Recommendations ?. Clinical Practice Guidelines for cancer care from the French National Federation of Cancer Centres (FNCLCC). Br J Cancer 2001; 84(Suppl2):1-92.
2. Fervers B, Leichtnam-Dugarin L, Carretier J, Delavigne V, Hoarau H, Brusco S, Philip T. The SOR SAVOIR PATIENT project--an evidence-based patient information and education project. Br J Cancer. 2003 Aug; 89 Suppl 1:S111-6.
3. Fervers B, Bataillard A, Carretier J, Kelson M. Involving cancer patients in clinical practice guidelines (CPGs) development in a French guidelines program: What are the key issues? Journal of Clinical Oncology, 2006 ASCO Annual Meeting Proceedings (Post-Meeting Edition).Vol 24, No 18S (June 20 Supplement), 2006: 16029.
4. Haute Autorite de Sante (Health National Authority). Etat des lieux. Patient et professionnels de sante : decider ensemble. Concept, aides destinees aux patients et impact de la decision medicale partageee, octobre 2013. http://www.has- sante.fr/portail/upload/docs/application/pdf/2013- 10/12iex04_decision_medicale_partagee_mel_vd.pdf
5. Cnamts (National Health Insurance Fund). Ameliorer la qualite du systeme de sante et maitriser les depenses : propositions de l'Assurance maladie pour 2014. Rapport au ministre charge de la securite sociale et au Parlement sur l'evolution des charges et des produits de l'Assurance maladie au titre de 2014 (loi du 13 aout 2004), juillet 2013. http://www.ameli.fr/fileadmin/user_upload/documents/cnamts_rapport_charges_produits_2014.pdf
Conflict of Interest:
Re:Any value of Early Warning Systems must rely on the prevalence of the conditions being sought
In reply to Bewley's response to our paper, we acknowledge that a number of studies have assessed the extent of major obstetric complications as higher than that cited in the RCOG publication [1-5]. Definitions as well as rate estimation of maternal morbidity vary widely across studies . However, the premise of our paper was not to minimise the scale and severity of the problem of maternal morbidity, but to explore the logic and perceived value of one particular safety solution, the MEOWS. In the light of our findings, we still conclude that the complexity of managing risk and safety within the maternity pathway, the associated opportunity costs of MEOWS and variation in implementation call into question its current role for routine use. We reiterate our belief that there is an urgent need for further research to validate the MEOWS for the maternity population.
References 1. Zhang WH, Alexander S, Bouvier-Colle MH, Macfarlane A; MOMS-B Group. Incidence of severe pre-eclampsia, postpartum haemorrhage and sepsis as a surrogate marker for severe maternal morbidity in a European population- based study: the MOMS-B survey. BJOG 2005;112:89-96. 2. Maternal Critical Care Working Group. Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman. London: RCOG Press, 2011 3. Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity - a case control study. Br Med J 2001;322:1089-94 4. Brace, Victoria, Gillian Penney, and Marion Hall. Quantifying severe maternal morbidity: a Scottish population study. BJOG: An International Journal of Obstetrics & Gynaecology 2004;111:481-484 5. Zanconato, Giovanni, et al. Severe maternal morbidity in a tertiary care centre of northern Italy: a 5-year review. Journal of Maternal-Fetal and Neonatal Medicine 2012;25:1025-1028.
Conflict of Interest:
Any value of Early Warning Systems must rely on the prevalence of the conditions being sought
Mackintosh et al. have made a useful contribution to the literature about pregnant and parturient's safety (1). The purpose of an Early Warning System (EWS) is to take action before deterioration that may require multiorgan support in intensive care. The ethnographic technique revealed many perceived benefits of a simple, graphic monitoring tool that empowered escalation of concerns. The research team highlighted inconsistencies in implementation of EWS, multiple competing charts for antenatal, intrapartum, postnatal and high dependency care and also resistance to medicalising normal birth. However, if EWSs do 'work' (which may yet need proving), their value will also depend on the nature and extent of problems which should not be understated.
The authors state "for every [maternal] death, nine women develop major obstetric complications including haemorrhage, infection, hypertensive disorders and thromboembolism". The RCOG reference cited is itself in error as it reported the numbers of women in the UK utilising critical care settings, (260 vs 14/ 100 000 maternities, a ratio of 19 high dependency and intensive care admissions to each death) (2). The report explains how definitions of severe morbidity vary, but that the number of major obstetric complications may be as high as 86-fold the number of deaths (1 200/ 100 000 maternities) (2,3). EWSs may also have an impact upstream on moderate morbidity with its commoner human and financial costs.
1. Mackintosh N, Watson K, Rance S, Sandall J. Value of a modified early obstetric warning system (MEOWS) in managing maternal complications in the peripartum period: an ethnographic study. BMJ Qual Saf 2013;0:1-9. doi:10.1136/bmjqs-2012-001781
2. Maternal Critical Care Working Group. Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman. London: RCOG Press, 2011:4
Conflict of Interest:
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