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We welcome new guidance from the Intensive Care Society on safer transfers for critically unwell pregnant and recently pregnant women within and between hospitals.
The guidance is for all members of the multidisciplinary team who may be involved in making a decision to transfer or carrying out the transfer.
Through our investigations, we have seen that harm can arise when transfers are conducted without careful consideration and planning. This has included investigations where some team members have been unaware that a transfer is taking place.
When multiple teams are involved, as is often the case in a maternity transfer, the chance of miscommunication can increase. Organisations need robust processes to ensure that relevant clinical and non-clinical details are shared effectively.
We have published our newest briefing paper examining cooling practices for newborn babies in our investigations where safety events occurred. A review of 20 investigations found that the national guidance on continuous temperature monitoring was not followed in 50% of the investigations.
Key concerns included the resuscitaire heater being turned off without appropriate monitoring, unrecordable admission temperatures of babies, and delays in starting continuous temperature monitoring.
Visit our website to read the briefing paper in full and our practical steps to help providers embed safe cooling practices across their services.
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