REFERENCES
1. World Health Organization (WHO). Quality of Care: A Process for Making Strategic Choices in Health Systems. Geneva: WHO; 2006.
2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st century.
Washington DC, National Academy Press; 2001.3. Edozien LC. The bionomic approach to patient safety and its application in gynaecological surgery. Best Pract Res Clin Obstet Gynaecol 2013;27:549-61.
4. Edozien LC. Situational awareness and its application in the delivery suite. Obstet Gynecol 2015;125:65-9.
5. Stanhope N, Vincent C, Taylor-Adams SE, O’Connor AM, Beard RW Applying human factors methods to clinical risk management in obstetrics. Br J Obstet Gynaecol 1997;104:1225-32.
6. Morello RT, Lowthian JA, Barker AL, McGinnes R, Dunt D, Brand C. Strategies for improving patient safety culture in hospitals: a systematic review. BMJ Qual Saf 2013;22:11-18.
7. Braithwaite J, Wears RL, Hollnagel E. Resilient health care: turning patient safety on its head. Int J Qual Health Care 2015;27:418-20.
8. Witter FR, Lawson P, Ferrell J. Decreasing cesarean section surgical site infection: an ongoing comprehensive quality improvement program. Am J Infect Control 2014;42:429-31.
9. Srofenyoh EK, Kassebaum NJ, Goodman DM, Olufolabi AJ, Owen MD. Measuring the impact of a quality improvement collaboration to decrease maternal mortality in a Ghanaian regional hospital. Int J Gynaecol Obstet 2016; 134:181-5.
10. Leung S, Leyland N, Murji A. Decreasing diagnostic hysteroscopy performed in the operating room: a quality improvement initiative. J Obstet Gynaecol Can 2016;38:351-6.
11. Nicolay CR, Purkayastha S, Greenhalgh A, et al. Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare. Br J Surg 2012;99:324-35.
12. Mason SE, Nicolay CR, Darzi A.
The use of Lean and Six Sigma methodologies in surgery: a systematic review. Surgeon 2015;13:91-100.13. The Health Foundation. Quality Improvement Made Simple, 2nd edn. London: Health Foundation; 2013.
14. Frost L. Reducing the overuse of βhCG measurements in the emergency gynaecology clinic. BMJ Qual Improv Rep 2016;5:u210039. w4218.
15. Knight M, Kenyon S, Brocklehurst P, et al. Saving Lives, Improving Mothers’ Care—Lessons Learned to Inform Future Maternity Care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-12. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2014.
16. Albright CM, Ali TN, Lopes V, Rouse DJ, Anderson BL. The Sepsis in Obstetrics Score: a model to identify risk of morbidity from sepsis in pregnancy. Am J Obstet Gynecol 2014;211:39.e1-8.
17. National Institute for Health and Care Excellence (NICE). Sepsis: Recognition, Diagnosis and Early Management. NICE guideline [NG51]. London: NICE; 2016.
18. Royal College of Obstetricians and Gynaecologists (RCOG). Bacterial Sepsis in Pregnancy. Green-top Guideline No. 64a. London: RCOG; 2012.
19. College of Emergency Medicine (CEM). Clinical Audits 20112012: Severe Sepsis and Septic Shock. London: CEM; 2012.
20. Steinmo S, Fuller C, Stone SP, Michie S. Characterising an implementation intervention in terms of behaviour change techniques and theory: the ‘Sepsis Six’ clinical care bundle. Implement Sci 2015;10:111.
21. Engelbrecht S, Wood EM, Cole-Sinclair MF. Clinical transfusion practice update: haemovigilance, complications, patient blood management and national standards. Med J Aust 2013;199:397.
22. Norfolk D (ed). Effective transfusion in obstetric practice. In: Handbook of Transfusion Medicine, 5th edn, pp. 105-12. Sheffield: UK Blood Services; 2013.
23. Royal College of Obstetricians and Gynaecologists (RCOG). Blood Transfusion in Obstetrics. Green-top Guideline No. 47. London: RCOG; 2015.
24. Scottish Health Council.
Good Practice in Service User Involvement in Maternity: Involving Women to Improve their Care. Edinburgh: Scottish Health Council; 2011.25. Edozien LC. Self-determination in childbirth: the law of consent. In O’Mahony D (ed), Medical Negligence and Childbirth. Dublin: Bloomsbury Professional; 2015.
26. General Medical Council (GMC). Consent: Patients and Doctors Making Decisions Together. London: GMC; 2008.
27. General Medical Council (GMC). Good Medical Practice. London: GMC; 2013. Available at: http://www.gmc-uk.org/gmp (accessed 12 June 2016).
28. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20.
29. Department of Health. The NHS Constitution for England. October 2015 Available at: https://www.gov.uk/government/ publications/the-nhs-constitution-for-england/the-nhs- constitution-for-england (accessed 12 June 2016).
30. Local Authority Social Services and National Health Service Complaints (England) Regulations 2009.
31. The Royal College of Obstetricians and Gynaecologists (RCOG). National Heavy Menstrual Bleeding Audit, Final Report. London: RCOG; 2014.
32. Healthcare Quality Improvement Partnership (HQUIP). National Pregnancy in Diabetes Audit Report, 2014: England, Wales and the Isle of Man. London: HQUIP; 2014.
33. Birthplace in England Collaborative Group, Brocklehurst P, Hardy P, et al. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011;343:d7400.
34. Johnston G, Crombie IK, Davies HT, Alder EM, Millard A. Reviewing audit: barriers and facilitating factors for effective clinical audit. Qual Health Care 2000;9:23-36.
35. Edozien LC. Mapping the patient safety footprint: the RADICAL framework. Best Pract Res Clin Obstet Gynaecol 2013;27:481-8.
36. Ward JK, Armitage G. Can patients report patient safety incidents in a hospital setting? A systematic review.
BMJ Qual Saf 2012;21:685-99.37. Taylor-Adams S, Vincent C. Systems analysis of clinical incidents: the London Protocol. Clin Risk 2004;10:211-20.
38. Lawton R, McEachan RR, Giles SJ, Sirriyeh R, Watt IS, Wright J. Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review. BMJ Qual Saf 2012;21:369-80.
39. Nicolini D, Waring J, Mengis J. Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the gap. Soc Sci Med 2011;73:217-25.
40. Taitz J, Genn K, Brooks V, et al. System-wide learning from root cause analysis: a report from the New South Wales Root Cause Analysis Review Committee. Qual Saf Health Care 2010; 19:e63.
41. Parliamentary and Health Service Ombudsman. A review into the quality of NHS complaints investigations where serious or avoidable harm has been alleged. December 2015. Available at: https:// www.ombudsman.org.uk/publications/review-quality-nhs- complaints-investigations-where-serious-or-avoidable-harm-has (accessed 5 April 2019).
42. Department of Health. Learning not Blaming: The Government Response to the Freedom to Speak Up Consultation, the Public Administration Select Committee report ‘Investigating Clinical Incidents in the NHS,, and the Morecambe Bay Investigation. London: Department of Health; 2015.
43. Department of Health. Report of the Expert Advisory Group. Healthcare Safety Investigation Branch. May 2016. Available at: https://www.gov.uk/government/publications/ improving-safety-investigations-in-healthcare (accessed 15 June 2016).
44. Royal College of Obstetricians and Gynaecologists (RCOG). Maternity Dashboard: Clinical Performance and Governance Score Card (Good Practice No. 7). London; RCOG; 2008.
45. Guha S, Hoo WP, Bottomley C. Introducing an acute gynaecology dashboard as a new clinical governance tool. Clin Govern Int J 2013;18:228-37.