National miscarriage misdiagnosis review

Hdl Handle:
http://hdl.handle.net/10147/128265
Title:
National miscarriage misdiagnosis review
Authors:
Health Service Executive (HSE); Incident Management Team
Publisher:
Health Service Executive (HSE)
Issue Date:
Apr-2011
URI:
http://hdl.handle.net/10147/128265
Item Type:
Report
Language:
en
Description:
On June 9th 2010, reports of 2 initial cases of misdiagnosis of miscarriage were reported in the Irish news media. A diagnosis of miscarriage had been made in error, and medical or surgical intervention was recommended to women, but subsequently it was found that the pregnancy was viable and the women went on to continue their pregnancies. Over the following weeks, several other women raised similar concerns with their hospitals. The Health Service Executive (HSE) put in place a series of immediate responses to the initial reports of misdiagnosis in early June 2010. Maternity hospitals and Early Pregnancy Assessment Units (EPAUs) around the country set up dedicated helplines, to provide information and support to women and their families who had questions about their diagnosis of early pregnancy loss. On June 10th 2010, a joint letter was sent by Dr. Tony Holohan, Chief Medical Officer at the Department of Health and Children, and Dr. Barry White, National Director for Quality and Clinical Care with the HSE, to all public and private obstetric and gynaecological facilities. The letter advised these facilities to immediately ensure that the decision to use drugs or surgical intervention in women who had a diagnosis of miscarriage was always approved by a Consultant Obstetrician. The HSE then set up a National Miscarriage Misdiagnosis Review to manage the incident and examine any similar cases that had occurred over the previous five years where drug or surgical treatment was recommended following a diagnosis of miscarriage, and where subsequent information demonstrated that the pregnancy was viable. The terms of reference stated that the review team was to be responsible for: 1. The satisfactory investigation of cases (systems analysis) to determine the causes and the response to the cases, and making recommendations as required. 2. Ensuring that any immediate risks identified during the course of the review were communicated immediately to the HSE for urgent management. 3. Providing their report to the then National Director of Quality and Clinical Care, HSE, who committed that this would be published. A five year timeframe (from 18th June 2005 to 18th June 2010) was agreed by the review team as being likely to encompass all cases that would be relevant to current practice and to allow the team to identify trends and patterns in the systems causes of these misdiagnoses. However the review team also considered any cases specifically submitted by service users that fell outside the five year timeframe, and cases identified through the Clinical Indemnity Scheme (CIS), where the case informed the work of the review team and the development of national standards.
Keywords:
PUBLIC HEALTH; MATNERITY SERVICE; HEALTH SERVICES AND THEIR MANAGEMENT
Local subject classification:
MEDICAL ERROR; MISDIAGNOSIS

Full metadata record

DC FieldValue Language
dc.contributor.authorHealth Service Executive (HSE)en
dc.contributor.authorIncident Management Teamen
dc.date.accessioned2011-04-18T15:08:22Z-
dc.date.available2011-04-18T15:08:22Z-
dc.date.issued2011-04-
dc.identifier.urihttp://hdl.handle.net/10147/128265-
dc.descriptionOn June 9th 2010, reports of 2 initial cases of misdiagnosis of miscarriage were reported in the Irish news media. A diagnosis of miscarriage had been made in error, and medical or surgical intervention was recommended to women, but subsequently it was found that the pregnancy was viable and the women went on to continue their pregnancies. Over the following weeks, several other women raised similar concerns with their hospitals. The Health Service Executive (HSE) put in place a series of immediate responses to the initial reports of misdiagnosis in early June 2010. Maternity hospitals and Early Pregnancy Assessment Units (EPAUs) around the country set up dedicated helplines, to provide information and support to women and their families who had questions about their diagnosis of early pregnancy loss. On June 10th 2010, a joint letter was sent by Dr. Tony Holohan, Chief Medical Officer at the Department of Health and Children, and Dr. Barry White, National Director for Quality and Clinical Care with the HSE, to all public and private obstetric and gynaecological facilities. The letter advised these facilities to immediately ensure that the decision to use drugs or surgical intervention in women who had a diagnosis of miscarriage was always approved by a Consultant Obstetrician. The HSE then set up a National Miscarriage Misdiagnosis Review to manage the incident and examine any similar cases that had occurred over the previous five years where drug or surgical treatment was recommended following a diagnosis of miscarriage, and where subsequent information demonstrated that the pregnancy was viable. The terms of reference stated that the review team was to be responsible for: 1. The satisfactory investigation of cases (systems analysis) to determine the causes and the response to the cases, and making recommendations as required. 2. Ensuring that any immediate risks identified during the course of the review were communicated immediately to the HSE for urgent management. 3. Providing their report to the then National Director of Quality and Clinical Care, HSE, who committed that this would be published. A five year timeframe (from 18th June 2005 to 18th June 2010) was agreed by the review team as being likely to encompass all cases that would be relevant to current practice and to allow the team to identify trends and patterns in the systems causes of these misdiagnoses. However the review team also considered any cases specifically submitted by service users that fell outside the five year timeframe, and cases identified through the Clinical Indemnity Scheme (CIS), where the case informed the work of the review team and the development of national standards.en
dc.language.isoenen
dc.publisherHealth Service Executive (HSE)en
dc.subjectPUBLIC HEALTHen
dc.subjectMATNERITY SERVICEen
dc.subjectHEALTH SERVICES AND THEIR MANAGEMENTen
dc.subject.otherMEDICAL ERRORen
dc.subject.otherMISDIAGNOSISen
dc.titleNational miscarriage misdiagnosis reviewen
dc.typeReporten
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