Maternity and neonatal (perinatal) adverse event review process: guidance

Operational guidance to support health boards boards undertaking perinatal adverse event reviews incorporating the additional reporting required of maternity services.

3. Overview of perinatal adverse event review pathway

The HIS National Framework identifies six stages of adverse event management.

1. Risk assessment and prevention

2. Identification and immediate actions following an adverse event, including consideration of duty of candour

3. Initial reporting and notification

4. Assessment and categorisation, including consideration of duty of candour

5. Review and analysis

6. Improvement planning and monitoring

When an adverse event occurs, the HIS Framework outlines the actions that should be taken (Fig 1):

Figure 1: 6 stages of adverse event management
This flow chart shows the six individual stages of how to manage an adverse event effectively.  Stage one risk assessment and prevention will also be returned to following stage six, improvement planning and monitoring, as the process is cyclical in nature.  Each stage in the flowchart has a box of suggested examples of steps that could be taken at each stage of the process.



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