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Risk management in gynaecology: principles and practice

https://doi.org/10.1016/j.bpobgyn.2007.03.005Get rights and content

The majority of gynaecology patients are fit women receiving relatively straightforward care. However, human error is inevitable. Furthermore, new treatments and technologies are constantly emerging, today's trainees are less experienced than their predecessors, and the need for team work is greater than ever. These and other factors pose threats to patient safety. Patient safety can be improved through risk management. This review describes risk management principles and tools applicable to gynaecology and highlights common sources of patient safety incidents in gynaecology clinics, wards and operating theatres. It provides an overview of communication, consent, staff training and supervision, and use of clinical practice guidance. Underlying theoretical principles are amply illustrated by practical examples.

Section snippets

Risk management strategy

The department or directorate of gynaecology should have its own risk management strategy. This is the compass guiding the unit towards improving patient safety. This strategy should complement the hospital or Trust-wide risk management strategy and should be interpreted and implemented within the context of organization-wide initiatives. The strategy should reflect the department's commitment to nurturing a culture of safety and delivering the highest possible standard of care to all women.

The

Gynaecology Risk Management coordinating group

Risk management activities in the department will typically be coordinated by a Gynaecology Risk Management Committee. In some units this function may be subsumed under a clinical governance committee which also addresses clinical audit and complaints. The Gynaecology Risk Management Committee will typically have multidisciplinary membership that includes:

  • clinical director or nominated clinical lead;

  • modern matron/lead nurse;

  • risk leads from various clinical areas, such as gynaecology wards,

Identifying, monitoring and controlling risk

Identifying risk is, put simply, finding answers to the question ‘what could go wrong?’ To answer this question we could look back at patient safety incidents that have occurred in the department. This is where incident reporting comes in. Analysis of reported incidents can reveal trends and show areas of weakness or unsafe practice in the department. Systems analysis (also called ‘root cause analysis’) of the more severe incidents can show features within the department that facilitate the

Communication

Communication is a recurring theme in patient safety. Almost always, communication failures underlie medical accidents, and gynaecology is no exception. Information regarding service provision and working practices should be readily available through team meetings, notice boards and briefings in the wards, clinic and theatres. There should be a personal, recorded handover of care between staff when there is a change of shift and when a patient is transferred from one professional to another.12

Clinical practice guidance

One safety lesson from ‘high reliability organizations’ (such as airlines) is that errors are less likely to happen if processes are standardized and if there is less reliance on memory. For example, administration of methotrexate to a woman carrying an intrauterine pregnancy is less likely to happen if her clinician has followed a treatment protocol underpinned by the risk management issues in this form of therapy for ectopic pregnancy. Staff should have access to referenced, evidence-based

Consent

All patients undergoing treatment should be given appropriate information on the nature and purpose of the treatment, benefits, alternatives and risks, and the consent process must comply with the hospital's consent policy. Good practice in consent is more than merely obtaining the patient's signature on a consent form. The consent form is a useful prompt for ensuring that benefits and risks are discussed, but the signatures on it are not a substitute for a proper discussion of the proposed

Staff training and development

Appropriate risk management in gynaecology also puts systems in place to ensure the competence and appropriate training of all professional staff. All job descriptions should include reference to responsibility for clinical governance, and this responsibility should be reviewed in the annual appraisal. All new professional staff will have appropriate induction and, where appropriate, mentorship or preceptorship arrangements. Robust arrangements must be in place to ensure that locum, bank or

Outpatient clinics

As part of the process of embedding risk management in gynaecology, the outpatients’ clinic should conduct a risk assessment, and the outcome of this exercise should inform the departmental risk register. Like other clinical areas the clinic should have its own risk management manual, policies, protocols and guidelines. These should cover issues such as the use of chaperones22, 23, obtaining consent17, ensuring positive patient identification24, logging of specimens dispatched to the

Pregnancy tests

In outpatient as well as inpatient facilities there should be ready availability of a pregnancy test, and it should be used. This reduces the chance that a woman will undergo surgical or medical treatment whilst carrying an undiagnosed pregnancy. In one case a coil was inserted without the doctor first excluding a pregnancy.26 The case was settled for £3500. Similar cases include contraceptive injection treatment of a pregnant patient27, and a gynaecological operation carried out without

Equality and diversity

The value of addressing equality and diversity issues extends beyond political correctness: there are also patient safety issues. The clinic should have policies and procedures for meeting the needs of women unable to communicate in the lingua franca and for addressing the special needs of women with a physical or cognitive disability and those with psycho-socio-economic deprivation. For example, a high rate of ‘did not attend’ (DNA) may be found in this group of patients, and there should be a

Operating theatres

One third of litigation cases relate to intraoperative problems.31 These are only the tip of the iceberg; many cases of harm or near miss do not proceed to litigation. General risk management principles such as teamwork, communication, training, and avoidance of fatigue are essential for protecting patient safety in operating theatres.32

Gynaecological surgeons should be familiar with clinical governance issues in their trade.33 It is particularly important for units to have systems in place

When things go wrong

Error cannot be totally eliminated, and sometimes error results in injury to a patient. When this happens, the gynaecologist should be open with the patient39 and offer every support that can be given.40

If the unit has a supportive culture that facilitates learning, there will also be appropriate support for the doctor. However, this only applies where the accident resulted from ‘an honest mistake’. In such cases there is usually a number of system factors leading up to the accident. The

Learning from experience

The gynaecology department committed to patient safety will promote a culture of learning and enquiry in which members of the team are encouraged to reflect on their individual and collective practice. In this regard, the leadership of the senior consultants is crucial. The service will also ensure that clinicians (senior or novice, doctor or nurse) involved in adverse incidents are offered appropriate support and advice.

Each system analysis report will include learning points and an action

System and individual

Much of what has been described in this chapter relates to a systems approach to patient safety. This approach is essential if quantum strides are to be made in advancing patient safety. However, it is not sufficient on its own – the individual practitioner must also incorporate and manifest basic principles of risk management in their everyday practice. All staff should be aware of, and relate to, cognitive biases which predispose to medical accidents. Every gynaecologist or nurse practitioner

Conclusion

The majority of gynaecology patients are fit women receiving relatively straightforward care. However, new treatments and technologies are constantly emerging, trainees are less experienced than their predecessors, and the need for team work is greater than ever. These and other factors pose threats to patient safety. Risk management appears to be more firmly entrenched in obstetrics, but is just as important in gynaecology. With risk management, we can offer safer gynaecological care.

Acknowledgement

An earlier version was published online by Elsevier (<http://dx.doi.org/10.1016/j.ogrm.2006.12.009>).

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