Prof. M.C.BansalMBBS., MS., FICOG., MICOG.

Founder Principal & Controller,Jhalawar Medical College & Hospital Jjalawar.

MGMC & Hospital , sitapura ., Jaipur

RISK MANAGEMENT IN OBSTETRIC & GYNAECOLOGY

Harvard Medical Practice Study(1991) : To err is human (1999) changed the world of risk management in medicine forever.

In their summary , it turned out that preventable errors in medical practice were more frequent, caused as much patient harm and cost a tremendous amount of money to the healthcare system.

Prominent problems in modern practice today include wrong side surgery, retained foreign body, surgical site infection, burns during surgery, mismatched blood transfusion and medication errors.

This is specially true for obstetrics & gynaecology where litigation is the highest all over the world.

If you know the problem ,the solution is quite clear.

Introduction

Human error is involved in 70% of all accidents including healthcare system.

Robert Helmeich a Psychologist and pioneer in error

management wrote Errors result from physiological and psychological limitations of human beings.

Causes of errors include fatigue, work load,fear, cognitive overload, poor inter personal communication imperfect information processing and flawed decision making.

The Problem

Effective error management is based on proper understanding of the nature and extent of human error.

Error /negligence ---SHAME AND BLAME--- The doctor at the end of chain of events is found guilty for committing the error and for the adverse clinical outcome which lead to

DEFAME.

The Problem

James reason’s Swiss cheese theory-No accident happens with out a series of mishaps illustrated by holes in slices of Swiss cheese , the slices represent the different stages in the process , while holes in the cheese represent active and passive errors with in each stage.

Main reasons for errors are inherent in the system, rather than being caused by an individual person in the system.

Don Bewrick CEO of institute of health care improvement----EVERY SYSTEM IS PERFECTLY DESIGNED TO ACHIEVE EXACTLY THE RESULTS IT GETS

The Problem

James Resason describes “Just Culture” –as an atmosphere of trust in which people are encouraged ( even awarded ) for providing essential safety – related information , but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior .

In all dangerous clinical situations ,where errors are triggered by environmental and personal factors – lead to errors and even harm to patient.

The Problem

In summary ,in order to reduce clinical risks successfully, it is necessary to solve the problems that arise because of the limitations of human performance , induced and enforced by environmental , personal or team factors .

In clinical practice –necessary skill, knowledge and to follow standardized routine procedure are mandatory.

With out specific risk management tools ,such as RM-SOPs and NOTCHES , all the efforts will have a very little effect in reducing clinical risk at front line.

The Problem

1 Situation awareness developing and maintaining a dynamic awareness of the situation in theatre, based on assembling data from the environment (patient, team, time, displays, equipments), understanding what they mean, analytical thinking ahead what may happen next

Gathering information Understanding information Projecting and Anticipating future state

NOTECHS – Non Technical skills

2 .Decision making skills for diagnosing the situation

and reaching a judgment in order to choose an appropriate course of action.

Considering various options Selecting and communicating

options Implementing and reviewing

decisions.

NOTECHS

3.Communication and team work Skills for working in a team context to

ensure that the team has an acceptable shared picture of the situation and can complete the task effectively and timely.

Exchanging information Establishing a shared

understanding Co-coordinating team activities

NOTECHS

4.Leadership Leading the team and providing direction,

demonstrating high standards of clinical practice and care and being considerate about the needs of individual team members.

Setting and maintaining standard Supporting others Coping with pressure

BASED ON THE CLASSIFICATIONOF FLIN ET AL.

NOTECHS

Acceptance and correct use of RM-SOPs is essential for effective risk reduction.

Table 1-tools of risk management - Checklist - Communication strategies (closed –loop, read back, repeat back

)

- Briefings - Debriefing

Risk Management tools and corresponding Standard Operating Procedures(RM-SOPs)

Table 2 - Correct use of check list - Skills of safe communication

strategies - Use of briefings - Use of debriefings

RM-SOPs----

Benefits It is easily demonstrated that humans

have very limited ability to remember more than 5 items at once. Activity like going to supermarket one prepares the list of glossary to be purchased.

Well designed and complete checklist prevents us from forgetting the things.

checklist additionally free our mind for other more complex and important problems that can not be managed success fully by such simple techniques.

Checklist

Clinical example Management of Eclampsia. - Well designed and complete checklist of

all the steps to be taken in a sequence will help in minimizing the errors and decreasing the risk.

- This in turn will help us in getting good fetal and maternal outcome.

Checklist----

Checklist are only effective if they are used every time you perform any specific procedure, even you are fully trained and experienced .

When you are tired, overworked or when there is some other operational problem ,you would like to avoid problems than only you will be convinced of the value of a checklist and trained in its use.

How To Perform the SOP

Benefits There are many situations when

be all desire clear and complete communication to other team members to ensure that right information is correctly transmitted.

Benefit is clear –there will be no confusion/ misunderstandings.

Clinical example----Ordering high risk medications such as cytotoxic chemotherapy or anticoagulant.

Closed Loop Communication

Think about asking telephone number/address. What we do ?

The technique is--- 1. Say it . 2. Ask the recipient to repeat it or write it down and read it. 3. Confirm it . This is west way to know whether the information has

been understood correctly. Technique is valuable when ordering high risk medicines that sound alike, such as

dioval/diovan, lasix/luvox,texol/taxotere and many others.

SOP HOW ?

Benefits Briefing is a structured type of

interaction used to achieve clear and effective communication in a timely manner .Each of us feel better as a team member if be know the plan of job to be done by the team.

It is evident that sports team or orchestras will perform best if all team members are aware of the plan well before the final show is to be performed.

Briefing

To make briefing successful. instructions must be clear, short and precise .Ideally there should also be the opportunity for questions from team members.

Briefing should take place as a minimum: (1) start of day,(2)Prior to procedure,(3)as the situation changes,(4) during hand offs(e.g.Tea break, shift change,etc)

How To Perform Briefing

Before starting the operation confirm the following important information's---

1.Indication of procedure. 2.recapitulate about steps of procedure.

3.Correct site and side. 4.Possible drug allergies . 5.previos drug reaction. 6.Special instruments/ suture material will be needed .

Clinical Example

Benefit Whenever the team has completed the

procedure , there should be a short session of all team members to review the mission.

This provides greatest chance for individual s and team to learn from present difficulties and problems faced during present operation and thereby improve their future strategies.

The entire team meats and reviews the management which has taken place. Three questions are to be answered (1)What went right (2) What did not go so well,(3)What we should do next time?

Debriefing

Technical skills are essential but are often inadequate to get everything right- for example a perfect operation done on wrong limb is perfect so far skilled technique of operation is concerned, this puts the team in problem.

This type of risk may be minimized by using so called “Non Technical Skills”

NOTECHS------

Non Technical Skills( NOTECHS)

A significant problem in dealing with NOTECHS is that they could not be measured objectively.

The NOTSS system developed by Prof. Rhona Flin and her team allows explicit rating and feedback to be given in relation to non technical skills.

It is ,in effect ,a behavioral marker system and may be used to structure training . It is also useful in evaluation of non technical skills in surgery a similar fashion to current practice in anesthesia, civil aviation and nuclear power industry.

How RM_SOPs and NOTECHS can be used together?

Certain catastrophes in medicine (e.g. wrong side surgery, Transfusion errors, left over packing in abdomen) Happen over and over again is a clear indicator that we have yet not solved the problem of risk reduction at the front line.

Paul Watzlawick: ‘ If you have not found a solution for your problem ,It is not the problem, but the solution you have to work on.

So what we can do to become as successful in risk and error reduction as high risk industries have been for many years?

Effective Risk Management in Clinical Practice

1. We have to accept that we, as humans, are limited in error free performance by the so called “human performance limitations”

2. To achieve this goal ,it is necessary to have interactive classroom teaching involving all members of healthcare team (nurses, doctors, midwives other assistants etc.)Did active teaching without interactivity will not achieve the target.

3. At the end trainees should be convinced that one needs SOPs of risk management to overcome The ‘human error’.

We have learn and reinforce the RM_SOPs that protect us from committing errors and help us in critical situation to achieve the best possible outcome ,whether working alone or in teams

Even if you are convinced of the value of RM-SOPs and have been trained to perform them correctly, it is likely that you will fail in life ,if you ignore the use of NOTECHS.

Lack of NOTECHS results in team and communication problems impairing good outcome.

One of the major problem in this context is the Heirachial structure of medical practice.

3.Subsequently after education and training in RM-SOPs ,one needs to be trained in NOTECHS To perform effective risk reduction.

1.The main reason for inadequate risk management in healthcare is the fact that the most care givers ignore effective strategies and need for appropriate systemic implementation of risk management at the front line

2.Hierachial working practices ., the shame and blame culture has to be eradicated in favor of a “just culture”.

3.The effective risk reduction is only possible when problems surrounding ethos, human performance limitations and non technical skills are taken in account and treated seriously.

4.OB-GY Specialists are frequently exposed to risky situations ,should learn and practice these effective strategies of RM-SOPs and NOTECHS.

Conclusion