MRCOG Small Group Exercise

Mr. Mohsen Iskander

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Small Group Exercise

• Group 1 – Blue- will work on Consent

• Group 2 – Red - will work on Risk Management

• Group 3 – Orange - will work on Audit

• Group 4- Yellow- will work on Complaint

• Group 5 – Green- Cochrane, Forest graph, Statistics, confidence interval. Research/evidence tools

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Blue Group 1 - Consent

• Mrs Judith Smith is 48 years old. She has

a long standing history of menorrhagia.

• She is known to have fibroid uterus

(16/40 size). Mrs Smith is booked for a

total abdominal hysterectomy and BSO.

• Describe the process of seeking consent

from Mrs Smith.

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Red Group 2 - Risk Management

• You are an ST5 undertaking diagnostic laparoscopy on a 35 year old patient with a history of two previous caesarean sections

• On examination of the pelvis, you noticed bowel adhesions to the abdominal wall and the presence of what appeared to be faecal matter in the pelvis.

• You suspect bowel injury which will require major bowel surgery.

• Discuss further management.

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Yellow Group 3 - Complaint

• A 28 year old woman had a normal delivery with a 2nd degree tear 4 weeks ago. Her perineum was sutured by an ST3 and she was discharged home the following day.

• She complained of offensive vaginal discharge and feeling unwell. Two weeks later, she attended her GP surgery. When the Practice Nurse was trying to take a vaginal swab, she found a retained swab in the vagina. The patient wrote a letter of complaint to the CEO.

• Your Consultant gave you the complaint and asked you to write a response as a training exercise on Governance issues.

• Describe the steps you take and the issues you need to cover in preparing such a response.

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Green Group 4 - Audit

You are an ST5 planning to undertake an audit project. You have

been asked by your Educational Supervisor to audit the management

of Heavy Menstrual Bleeding (HMB). You need to consider:

a) How would you design your audit

b) The factors that can affect the quality of the audit

c) Reasons for lapses if present and ways to improve compliance

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Plenary- Consent 1

• Does the patient have capacity?

• Is the consent given voluntarily?

• Has the patient received sufficient information?

• - The nature and purpose of the procedure

• - Options of treating the condition/no treatment

• - The benefits

• - Side effects, complications and other risks (Material Risk)

• - Additional procedures/Blood transfusion

• - Type of anaesthesia

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Plenary –Consent 2

• Focus on the patient’s “individual situation”

• “Cooling off” period

• Confirmation of consent (2nd part)

• Give copy of the consent to the patient

and leaflets• References:

• Mental Capacity Act 2002

• Consent - Patients and Doctor making decisions together GMC 2008

• Reference Guide to Consent for examination or treatment DOH 2009

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Plenary- Risk Management 1

During the procedure (immediate action)

1) Stop the procedure

2) Inform:

● Consultant Gynaecologist

●Anaesthetist

● Scrub Nurse

● Colorectal Surgeon

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Plenary- Risk Management 2

3) Steps to take following the incident

● Complete an incident form

● Ensure your notes are completed accurately

● Discuss the event with your Education Supervisor

● Take part in the debrief with the team involved.

● Write a reflection of the event

● If requested, write a formal statement with help from a member of the Risk Management team

● Engage fully with the investigation

● Get support if required.

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Plenary- Risk Management 3

4) Debrief

● Describe the incident and the required intervention

● Apologise if one is needed.

● Discuss post op care and recovery

● Discuss prognosis

● Appropriate follow up

● Write to GP

● Lessons learned

● Training issues.

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Plenary- Complaint 1

• Refer to clinical records

• Indentify yourself at the beginning of the report with full name, qualifications, experience and status

• Identify the staff who were involved in the case (Midwives, medical)

• Give a factual description of the chronology

• Describe the incident which led to the complaint in detail.

• Identify any good practice points

• Identify any lapses or malpractice which could have led to the incident

• Retained foreign object post operation is a never event –Treat as a Serious Incident Requiring Investigation (SIRI)

• Incident form and investigation

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Plenary- Complaint 2

• Consider the National Patient Safety Agency (NPSA) report in reducing the risk of retained swabs after vaginal births

- Count swabs before and after the procedure

- Record the count in the case records

- Use swabs that have safety features, such as tails or tags

- Perform VE/PR after the procedure

• Apologise to the woman/could arrange a meeting

• Review Labour Ward protocols/guidelines

• Training issue

• Inform GP

Reference:

1) The Never Event list Department of Health 2012/2013

2) Rapid Response Report (RRR) from the NPSA 2010

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Plenary- Audit 1

Audit Design

● Agree the audit scope and objectives – sample size

● Audit methodology/design duration of the study –prospective/retrospective

● Review literatures and national guidelines (NICE 2007, RCOG 2008) to define auditable standards

● Design proforma/audit tools

● Decide on the outcome measures

● Collection and analysis of data

● Conclusion and recommendations

● Consider need for re-audit

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Plenary- Audit 2

Factors which can affect the quality of audit

● Sample size/bias

● Strength of auditable standards

● Complaint with national requirements for

quality improvement (CQC)

● Confidentiality (Anonymity)

● Multidisciplinary

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Plenary- Audit 3

Ways to improve compliance

●Consider multifactorial reasons for lapses

- Organisational

- Human lapses

- Resources

●Sensitive feedback to stakeholders

● Consider modification/update of local protocol

● You may undertake study/questionnaire of staff to ascertain why compliance

is poor

● Arrange training if needed

● Action plan to implement recommendations

● Re-Audit

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