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Risk Management in Obstetrics and Gynaecology – Multiple Choice Answers for Vol. 27, No. 4
Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A7–A13
Contents lists available at SciVerse ScienceDirect
Best Practice & Research Clinical Obstetrics and Gynaecology journal homepage: www.elsevier.com/locate/bpobgyn
Risk Management in Obstetrics and Gynaecology – Multiple Choice Answers for Vol. 27, No. 4 1. a) F b) F
c) F
d) T e) F
Sometimes we learn by ‘trial and error’ and error can also result in serendipitous discovery. Safety skills can be both taught and learned and both teams and individuals can lose situational awareness. Latent conditions do indeed increase the likelihood of active failures and can be caused or influenced by clinicians as well as managers. 2. a) F b) F
c) T d) F e) F
The bionomic approach is based on ecosystems. It advocates individual responsibility, not a culture of blame. High safety resilience is all about anticipation and mitigation of accidents and their effects. There are numerous examples of safety resilience in ecology. One can demonstrate leadership qualities without heading a team. 3. a) T b) T c) F
d) T e) T
The counting process has become automatic, which may make practitioners complacent about their attention to detail. This attention to detail may become particularly difficult when theatre environment is full of distractions, such as phone calls, theatre practitioners leaving the room for additional supplies, and excessive talking by team members. Analysis of 9923 surgical records revealed that the time of day and length of surgery correlated with an increased incidence of swab and instrument count discrepancies, most of which occurred when multiple theatre teams were involved in the same surgical procedure. When multiple teams are involved, an additional layer of complexity and potential fallibility exists, owing to handover and the potential for communication failures, which may increase the likelihood of count discrepancies. The accuracy of the counting process depends on factors related to the complexity of the surgery, whether the surgery was performed on an emergency or urgent basis, and factors related to the surgical team’s fatigue and workload. The incidence of retained swabs and instruments is increased in people with high body mass index. 4. a) F b) T c) F d) T e) T Between April 2007 and March 2009, 99 incidents of swabs left in the vagina after birth were reported by healthcare staff in England and Wales. To reduce the risk of retained swabs after vaginal delivery, the National Patient Safety Agency recommended that all the NHS organisations in England and Wales that provide maternity services should: (1) have written procedures in place for swab counts
DOI of original article: http://dx.doi.org/10.1016/j.bpobgyn.2013.05.003. 1521-6934/$ – see front matter http://dx.doi.org/10.1016/j.bpobgyn.2013.05.004
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Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A7–A13
at all births (including perineal suturing); (2) audit swab count practices in their maternity services; (3) provide education and training about the counting procedure for all midwifery, obstetric and support staff; (4) ensure that lead professionals (midwives and obstetricians) are aware of their responsibility for documenting the completed swab count in the woman’s health record; (5) in conjunction with their supplies department, risk assess sterile delivery and perineal suture packs and consider using X-ray detectable swabs; (6) ensure staff report incidents of swabs retained after vaginal births and perineal suturing as patients’ safety incidents; and (7) cascade the clinical briefing sheet to relevant staff to raise awareness of the risks of swabs being unintentionally retained following vaginal births and perineal suturing. 5. a) T b) T c) T d) T e) T The most common foreign body unintentionally left inside patient during surgery is the swab. This is not surprising as so many are used in each procedure, especially when there is excessive bleeding. Despite the fact that X-rays have been used to find missed swabs, it is not accurate every time. Research has found that radiological diagnosis of a retained swab is difficult because the radio-opaque line may become twisted or hidden behind dense tissue. The variable appearance of retained surgical swab can lead to diagnostic misinterpretations. In a report of 13 patients with a retained swab, the radio-opaque marker was only visible in nine X-rays and, even then, there was no recognition for what it was. Retained surgical instruments are easier to identify on postoperative X-rays, but needles or parts of needles pose considerable challenge to diagnose, especially if the needle is smaller than 10 mm. The Association of Perioperative Registered Nurses does not recommend using X-ray if the missed needle is smaller than 4 mm. The other difficulty in diagnosis is that retained swabs and instruments may not present immediately after the surgery. They can present some years after that, often after patients have presented with symptoms of persistent but unexplained pain. 6. a) F b) F c) F
d) T e) F
Most clinical errors have a system or latent organisational basis. Although a high number of claims arise from ultrasound non-detection of fetal abnormalities, the majority of claims in the UK are for cerebral palsy, interpretation of cardiotocography and management of labour. Most pregnancy losses following amniocentesis are unexplained. Studies have shown that repeated scanning may not improve visualisation of fetal parts. Average detection of significant fetal abnormality by all the appropriately designed studies does not exceed 60%, although this varies with the organ involved and the nature of the abnormality. 7. a) F b) T c) F
d) F e) T
The attributable fetal loss rate for twins is about 1.6%. It is increased over the rates for singleton amniocentesis of 1% but best estimates do not suggest a doubling of risk. Monochorionicity confirms a monozygotic pregnancy and as such the risks of aneuploidy is usually identical for both fetuses. A single uterine puncture approach is an acceptable alternative where technically feasible. Risk of amniotic fluid contamination is minimised by discarding a small amount of amniotic fluid sample following access of the second amniotic sac by traversing the intertwin septum. Combining NT with biochemical serum markers improves the sensitivity of the screening estimation and reduces the false positive rate. A transvaginal approach may sometimes be required to gain access to one of the two placental masses. 8. a) F b) F c) T d) T e) T Adverse events can be defined as unintended injuries or complications that are caused by healthcare management, rather than by the patient’s underlying disease, that lead to death, disability at the time of discharge, or prolonged hospital stay. Adverse events can occur as a result of a faulty health system, a clinical decision or clinical procedure, or problems inherent within products. Therefore, it is not only a result of an incorrect diagnosis and also not defined as a complication of the underlying disease. One of
Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A7–A13
A9
the major consequences of adverse events in health care is that it prolongs hospital stay and therefore increases the cost of care for the patient. It is true that the mortality and preventability of adverse events in developing countries are considerably higher than in developed countries. A systematic review in 10 African countries of 15,548 hospital records revealed that at least one adverse event occurred in 8.2% of patients, with a range of 2.5–18.4% per country. As high as 30% of the cases, were associated with the death of a patient. Over three-quarters (83%) were judged to be preventable. A systematic review of in-hospital adverse events among a total of 74,485 patients revealed the median overall incidence of hospital adverse events to be 9.2%, and 7.4% of the events were lethal. It further revealed that 43.5% of the adverse events were preventable and more than one-half (56.3%) of patients experienced no or minor disabilities. It is also true that the rate of adverse events is an indication of patient safety. Improvement of patient safety can reduce the rate of adverse events in the healthcare system. 9. a) T b) T c) F
d) F e) T
A major contributor to unsafe care is the breakdown of the organisational structure of the health system. The fact that the health system involves many interdependent organisations (e.g. administrators, professional bodies, legislators and manufacturers) further complicates the organisational structure. Another structural factor that leads to unsafe care is breakdown of communication between various healthcare workers in the health system. The process factors identified are misdiagnosis, lack of adequate follow up of tests; lack of appropriate treatment in a timely manner; counterfeit and substandard drugs; and unsafe injection practices. If as high as 10–15% of diagnoses are incorrect in developed countries with sophisticated technology, it is safe to assume that the percentage of misdiagnosis will be higher in developing countries. This clearly shows that misdiagnosis is not only a problem of developing countries. Advancements in medical technology are often thwarted by the lack of human ability to use technology effectively, and this has been identified as a major structural factor that leads to unsafe care. One of the structural factors identified by the expert group of the Alliance is inadequate number of qualified healthcare providers worldwide, which is a key structural issue that affects patient safety. A deficit of 24 million doctors, nurses, and midwives, has been estimated globally in about 57 countries. This is a huge challenge, and an even greater challenge in developing countries. 10. a) F b) F
c) F
d) T e) T
Pre-surgical briefings and checklists are designed to prepare teams to counter threats and minimise potential errors, not just to ensure availability of instruments. Studies have shown that pre-surgery briefings reduce communication errors. Team communication and cohesion is also improved with briefings. Comparisons have been made between the operating theatre and aviation industry, and not the manufacturing industry, as they are both high risk and stressful environments. Both have different professionals that work with advanced technology, with challenges from various environmental sources. The aviation industry has greatly reduced errors by introducing crew resource management, which has standardised teamwork and communication; the operating theatre has not yet achieved this. One of the key factors responsible for surgical adverse events is lack of effective communication and good team work rather than lack of surgical skills. A common cause of inadvertent patient harm in the operating theatre is communication failure. It is true that unidirectional change in attitude in the operating theatre can create a patient safety climate more conducive to effective communication and team work. Team-based patient safety education will ensure training of health care workers in the operating theatre as a team. This will enhance better team communication and cohesion, which are keys to preventing surgical adverse events. 11. a) F b) T c) F d) F e) T HAI, also known as nosocomial infection, is defined as an infection acquired by a patient on admission to a healthcare facility or occurring immediately after discharge that was not manifesting or incubating at the time of admission. It is not a complication of the patient’s disease. Catheter-related urinary-tract infection, surgical-site infection and hospital-acquired pneumonia are the three most
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Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A7–A13
common HAIs in developing and developed countries, with blood-stream infection as the fourth most common HAI in developed countries. The statement that one of the measures used in preventing HAI in developing countries include use of potent antibiotics for managing these infections is untrue. Instead, the measures include establishment of hospital infection control committees, training of healthcare workers on infection control, and development of policies on hand hygiene. Others are development of policies on antibiotic use in hospitals and policies on medical waste management. In developed countries, much has been documented on the burden of HAI, where its prevalence is 5–15% of patients on admission in regular wards and as high as 50% or more in patients admitted to intensive care units. This shows that patients in intensive care units are at high risk of HAI. 12. a) T b) F
c) T d) T e) T
If the CTG is normal, the risk of acidosis is negligible, but 50% of pathological CTG traces are not associated with acidosis. Babies with acidaemia do not exhibit FHR accelerations. 13. a) T b) T c) T d) T e) T These time frames demonstrate the resilience of well-grown fetuses without risk factors. The obstetrician or midwife, however, does not know for sure that the baby is well grown. 14. a) T b) T c) F
d) F e) T
Total and persistent body movement characterises fetal behaviour in the first half of the pregnancy. Fetal movements diminish with maturity and the development of rapid eye movement sleep pattern. Accelerations are hard wired in fetal neurological behaviour and they occur independent of fetal movement. 15. a) T b) T c) T d) F e) T The development of intrapartum hypoxia is manifested by the development of fetal heart rate decelerations, which must provoke an increase in baseline fetal heart rate or persistent bradycardia. A normal fetal heart rate variability suggests neurological integrity and a low risk of significant hypoxia, acidaemia, or long-term neurological deficit. 16. a) F b) T c) T
d) T e) F
The MOREOB Program is delivered in modules each with a specific name. The first module is called ‘learning together’ the second module is ‘working together’; and the third module has the title of ‘changing the culture’. 17. a) F b) F c) F
d) T e) F
The inter-disciplinary ranges calculated for the pre-test results and for post test results that correspond with the completion of module three is 12%. 18. a) F b) F c) T d) F e) F The percent changes for each element tested in the Culture Assessment Survey show that the patient safety category had the biggest change at 20%. 19. a) F b) F c) T d) F e) F Other approaches without measurements, such as implementing clinical guidelines or undergoing an accreditation process, can be used to improve quality of care. Measurement, however, plays an
Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A7–A13
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important part in improving quality of care and promoting beneficial changes. New treatments and technologies are constantly emerging that have made maternal death a rare event in industrialised countries. Consequently, maternal mortality lacks sensitivity as a marker for the quality of obstetrical care. Maternal and neonatal deaths, especially in industrialised countries, have become rare and are often preventable by good healthcare. Today, parents expect not only survival of the mother and neonate, but also maintenance of good health, optimal comfort for the mother and baby, and an overall positive experience. Therefore, other quality indicators must be used. In recent years, numerous quality measures have been proposed in obstetrics. A number of national and international organisations and professional bodies have developed several quality indicators. To date, consensus is yet to be reached on the best set of measures. 20. a) T b) F c) T d) T e) T The CUSUM chart can be used as a dashboard to monitor quality indicators in maternity units. Several statistical process control have been adapted for use in medicine, including the Shewhart chart and funnel plot. An advantage of the CUSUM approach over other quality-control charts is that the entire history of the healthcare activity is considered when determining the result after each new episode of activity. This characteristic enables CUSUM charts to detect fluctuations in indicator rates that may not be evident from aggregate data analysis. For CUSUM charts, p0 (the acceptable rate) is the rate for which activity is considered ‘normal’ and no investigation is necessary. In contrast, p1 represents an unacceptable rate and indicates that an audit is needed, regardless of whether corrective action is required. 21. a) T b) F c) F d) F e) F The Delphi technique is a structured process that uses a series of questionnaires or ‘rounds’ to gather information. Rounds are held until group consensus is reached. The Delphi technique is a systematic approach in which indicator selection relies directly on the available evidence complemented with expert opinion. In the Delphi process, the participants never meet. This characteristic avoids domination of the consensus process by one or a few experts. The Delphi process permits the participation of a large number of individuals across diverse locations and areas of expertise. 22. a) F b) F
c) F
d) F e) T
The RADICAL framework emphasises the dynamic relationship between person and system. The domains in RADICAL should not be treated as silos; integration of the domains is a quintessential attribute of the framework. The framework proclaims a worldview of patient safety, emphasises the role of individuals in creating safety and the interdependence of various components of the system. Qualitative and quantitative data may be collected. Schema theory and a bionomic approach to patient safety both underpin this framework. 23. a) F b) F
c) T d) F e) T
In sepsis, blood cultures and swabs should be taken before antibiotic treatment is started but should not delay treatment. They are vital in terms of ongoing management as they provide microbiological diagnosis and sensitivity which may well alter choice of anti-microbial. 24. a) F b) T c) F d) F e) F Ampicillin and first-generation cephalosporins are equally effective in reducing postoperative endometritis. A single intravenous dose of first-generation cephalosporin is as efficacious as multiple doses of broad-spectrum agents. Anaerobic cover is only usually necessary for treatment when there is suspected infection.
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Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A7–A13
25. a) T b) T c) F
d) T e) F
About one-half of maternal deaths are avoidable, and errors in communication are a common reason for substandard care. Misinterpretation of electronic fetal monitoring is a cause for cerebral palsy attributable to intrapartum events. The risk of brachial plexus injury can be reduced with evidence-based management of shoulder dystocia. The cost of maternity claims in England is as high as all the other specialties together. 26. a) T b) F
c) T d) F e) F
SBAR, closed-loop communication, and awareness of the clinical situation, team, and patient focus, are strategies associated with better team efficiency in managing emergencies. Leaders should be the team member most experienced in the specific emergency at hand, regardless of profession or seniority rank. Although it might be useful to designate a specific team member to communicate with women, what is more important is the content of the messages. 27. a) T b) F
c) T d) F e) T
Training from undergraduate level can prevent interprofessional barriers and improve teamwork in maternity. Training should be interprofessional, for all staff, and include hybrid simulation with patient actors so that participants can practise communication skills. Formal assessment of participants has not been shown to improve outcomes. 28. a) F b) T c) T
d) F e) F
Although UKOSS can be used to undertake observational studies comparing the outcomes of different treatments, individual women are not randomised and the system cannot be used to conduct randomised-controlled trials. UKOSS can be used to monitor the effect of the introduction of a new treatment where the disease treated or prevented is rare. For example, a UKOSS study of eclampsia showed the effect of the introduction of therapeutic and prophylactic magnesium sulphate. Studies can be rapidly introduced if there are safety concerns raised about new treatments or policies; for example, a UKOSS study to measure the incidence of anaphylaxis is being conducted to address concerns about new antibiotic prophylaxis policies. UKOSS is principally designed to study rare complications that require a large collaboration to generate robust information. Common complications can be studied on an individual, hospital or regional basis. Although observational studies can provide information about the relative effectiveness of different treatments, they are not interventional studies and cannot therefore formally test efficacy. Any differences observed may be due to uncontrolled confounding, and a randomised study design is the only way to robustly account for this. In situations in which randomised trials are difficult or impossible, however, population-based observational studies may provide the highest quality evidence available. 29. a) T b) T c) T d) F e) F The data collected for UKOSS studies includes details of patient management, thus individual hospitals can use these data to assess whether their practice conforms to guidelines where these exist. The conditions studied using UKOSS may themselves be outcomes (e.g. peri-partum hysterectomy as an outcome of severe postpartum haemorrhage), or may themselves have outcomes that can be used by hospital units for monitoring purposes (e.g. hypoxic brain injury as an outcome of amniotic fluid embolism). Studies conducted using UKOSS can provide information about risk factors for individual conditions and can thus be used to identify high-risk populations. This information, in conjunction with data about the characteristics of a population served by the hospital, can be used to help design appropriate services. Although UKOSS can identify variations in disease incidence, more detailed information, such as through confidential case review, is likely to be needed to fully investigate these variations. Similarly, quality of care is better assessed with a more detailed case review process, as UKOSS data will only capture some aspects of care.
Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A7–A13
A13
30. a) F b) T c) F d) T e) F Uterine rupture occurs in about one in every 500 women who have had a prior caesarean section who plan vaginal delivery. Overall, 26% of women had a hysterectomy after management or refractory haemorrhage with uterine compression sutures, interventional radiological techniques, pelvic vessel ligation or factor VIIa. Maternal 2009A(H1N1) infection is associated with a statistically significantly higher risk of poor pregnancy outcomes, including preterm delivery (aOR 4.0, 95% CI 2.7 to 5.9), stillbirth (aOR 4.2, 95% CI 1.4 to 12.4), and perinatal mortality (aOR 5.7, 95% CI 2.2 to 15.1). Both Black African women (relative risk 2.35, 95% CI 1.45 to 3.81) and Black Caribbean women (RR 2.45, 95% CI 1.81 to 3.31) have a higher risk of specific severe maternal morbidities when compared with white women. Comparison of similar studies suggests that eclampsia occurs more frequently in the Netherlands and Scandinavia compared with the UK.
Contents lists available at SciVerse ScienceDirect
Best Practice & Research Clinical Obstetrics and Gynaecology journal homepage: www.elsevier.com/locate/bpobgyn
Risk Management in Obstetrics and Gynaecology – Multiple Choice Answers for Vol. 27, No. 4 1. a) F b) F
c) F
d) T e) F
Sometimes we learn by ‘trial and error’ and error can also result in serendipitous discovery. Safety skills can be both taught and learned and both teams and individuals can lose situational awareness. Latent conditions do indeed increase the likelihood of active failures and can be caused or influenced by clinicians as well as managers. 2. a) F b) F
c) T d) F e) F
The bionomic approach is based on ecosystems. It advocates individual responsibility, not a culture of blame. High safety resilience is all about anticipation and mitigation of accidents and their effects. There are numerous examples of safety resilience in ecology. One can demonstrate leadership qualities without heading a team. 3. a) T b) T c) F
d) T e) T
The counting process has become automatic, which may make practitioners complacent about their attention to detail. This attention to detail may become particularly difficult when theatre environment is full of distractions, such as phone calls, theatre practitioners leaving the room for additional supplies, and excessive talking by team members. Analysis of 9923 surgical records revealed that the time of day and length of surgery correlated with an increased incidence of swab and instrument count discrepancies, most of which occurred when multiple theatre teams were involved in the same surgical procedure. When multiple teams are involved, an additional layer of complexity and potential fallibility exists, owing to handover and the potential for communication failures, which may increase the likelihood of count discrepancies. The accuracy of the counting process depends on factors related to the complexity of the surgery, whether the surgery was performed on an emergency or urgent basis, and factors related to the surgical team’s fatigue and workload. The incidence of retained swabs and instruments is increased in people with high body mass index. 4. a) F b) T c) F d) T e) T Between April 2007 and March 2009, 99 incidents of swabs left in the vagina after birth were reported by healthcare staff in England and Wales. To reduce the risk of retained swabs after vaginal delivery, the National Patient Safety Agency recommended that all the NHS organisations in England and Wales that provide maternity services should: (1) have written procedures in place for swab counts
DOI of original article: http://dx.doi.org/10.1016/j.bpobgyn.2013.05.003. 1521-6934/$ – see front matter http://dx.doi.org/10.1016/j.bpobgyn.2013.05.004
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Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A7–A13
at all births (including perineal suturing); (2) audit swab count practices in their maternity services; (3) provide education and training about the counting procedure for all midwifery, obstetric and support staff; (4) ensure that lead professionals (midwives and obstetricians) are aware of their responsibility for documenting the completed swab count in the woman’s health record; (5) in conjunction with their supplies department, risk assess sterile delivery and perineal suture packs and consider using X-ray detectable swabs; (6) ensure staff report incidents of swabs retained after vaginal births and perineal suturing as patients’ safety incidents; and (7) cascade the clinical briefing sheet to relevant staff to raise awareness of the risks of swabs being unintentionally retained following vaginal births and perineal suturing. 5. a) T b) T c) T d) T e) T The most common foreign body unintentionally left inside patient during surgery is the swab. This is not surprising as so many are used in each procedure, especially when there is excessive bleeding. Despite the fact that X-rays have been used to find missed swabs, it is not accurate every time. Research has found that radiological diagnosis of a retained swab is difficult because the radio-opaque line may become twisted or hidden behind dense tissue. The variable appearance of retained surgical swab can lead to diagnostic misinterpretations. In a report of 13 patients with a retained swab, the radio-opaque marker was only visible in nine X-rays and, even then, there was no recognition for what it was. Retained surgical instruments are easier to identify on postoperative X-rays, but needles or parts of needles pose considerable challenge to diagnose, especially if the needle is smaller than 10 mm. The Association of Perioperative Registered Nurses does not recommend using X-ray if the missed needle is smaller than 4 mm. The other difficulty in diagnosis is that retained swabs and instruments may not present immediately after the surgery. They can present some years after that, often after patients have presented with symptoms of persistent but unexplained pain. 6. a) F b) F c) F
d) T e) F
Most clinical errors have a system or latent organisational basis. Although a high number of claims arise from ultrasound non-detection of fetal abnormalities, the majority of claims in the UK are for cerebral palsy, interpretation of cardiotocography and management of labour. Most pregnancy losses following amniocentesis are unexplained. Studies have shown that repeated scanning may not improve visualisation of fetal parts. Average detection of significant fetal abnormality by all the appropriately designed studies does not exceed 60%, although this varies with the organ involved and the nature of the abnormality. 7. a) F b) T c) F
d) F e) T
The attributable fetal loss rate for twins is about 1.6%. It is increased over the rates for singleton amniocentesis of 1% but best estimates do not suggest a doubling of risk. Monochorionicity confirms a monozygotic pregnancy and as such the risks of aneuploidy is usually identical for both fetuses. A single uterine puncture approach is an acceptable alternative where technically feasible. Risk of amniotic fluid contamination is minimised by discarding a small amount of amniotic fluid sample following access of the second amniotic sac by traversing the intertwin septum. Combining NT with biochemical serum markers improves the sensitivity of the screening estimation and reduces the false positive rate. A transvaginal approach may sometimes be required to gain access to one of the two placental masses. 8. a) F b) F c) T d) T e) T Adverse events can be defined as unintended injuries or complications that are caused by healthcare management, rather than by the patient’s underlying disease, that lead to death, disability at the time of discharge, or prolonged hospital stay. Adverse events can occur as a result of a faulty health system, a clinical decision or clinical procedure, or problems inherent within products. Therefore, it is not only a result of an incorrect diagnosis and also not defined as a complication of the underlying disease. One of
Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A7–A13
A9
the major consequences of adverse events in health care is that it prolongs hospital stay and therefore increases the cost of care for the patient. It is true that the mortality and preventability of adverse events in developing countries are considerably higher than in developed countries. A systematic review in 10 African countries of 15,548 hospital records revealed that at least one adverse event occurred in 8.2% of patients, with a range of 2.5–18.4% per country. As high as 30% of the cases, were associated with the death of a patient. Over three-quarters (83%) were judged to be preventable. A systematic review of in-hospital adverse events among a total of 74,485 patients revealed the median overall incidence of hospital adverse events to be 9.2%, and 7.4% of the events were lethal. It further revealed that 43.5% of the adverse events were preventable and more than one-half (56.3%) of patients experienced no or minor disabilities. It is also true that the rate of adverse events is an indication of patient safety. Improvement of patient safety can reduce the rate of adverse events in the healthcare system. 9. a) T b) T c) F
d) F e) T
A major contributor to unsafe care is the breakdown of the organisational structure of the health system. The fact that the health system involves many interdependent organisations (e.g. administrators, professional bodies, legislators and manufacturers) further complicates the organisational structure. Another structural factor that leads to unsafe care is breakdown of communication between various healthcare workers in the health system. The process factors identified are misdiagnosis, lack of adequate follow up of tests; lack of appropriate treatment in a timely manner; counterfeit and substandard drugs; and unsafe injection practices. If as high as 10–15% of diagnoses are incorrect in developed countries with sophisticated technology, it is safe to assume that the percentage of misdiagnosis will be higher in developing countries. This clearly shows that misdiagnosis is not only a problem of developing countries. Advancements in medical technology are often thwarted by the lack of human ability to use technology effectively, and this has been identified as a major structural factor that leads to unsafe care. One of the structural factors identified by the expert group of the Alliance is inadequate number of qualified healthcare providers worldwide, which is a key structural issue that affects patient safety. A deficit of 24 million doctors, nurses, and midwives, has been estimated globally in about 57 countries. This is a huge challenge, and an even greater challenge in developing countries. 10. a) F b) F
c) F
d) T e) T
Pre-surgical briefings and checklists are designed to prepare teams to counter threats and minimise potential errors, not just to ensure availability of instruments. Studies have shown that pre-surgery briefings reduce communication errors. Team communication and cohesion is also improved with briefings. Comparisons have been made between the operating theatre and aviation industry, and not the manufacturing industry, as they are both high risk and stressful environments. Both have different professionals that work with advanced technology, with challenges from various environmental sources. The aviation industry has greatly reduced errors by introducing crew resource management, which has standardised teamwork and communication; the operating theatre has not yet achieved this. One of the key factors responsible for surgical adverse events is lack of effective communication and good team work rather than lack of surgical skills. A common cause of inadvertent patient harm in the operating theatre is communication failure. It is true that unidirectional change in attitude in the operating theatre can create a patient safety climate more conducive to effective communication and team work. Team-based patient safety education will ensure training of health care workers in the operating theatre as a team. This will enhance better team communication and cohesion, which are keys to preventing surgical adverse events. 11. a) F b) T c) F d) F e) T HAI, also known as nosocomial infection, is defined as an infection acquired by a patient on admission to a healthcare facility or occurring immediately after discharge that was not manifesting or incubating at the time of admission. It is not a complication of the patient’s disease. Catheter-related urinary-tract infection, surgical-site infection and hospital-acquired pneumonia are the three most
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Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A7–A13
common HAIs in developing and developed countries, with blood-stream infection as the fourth most common HAI in developed countries. The statement that one of the measures used in preventing HAI in developing countries include use of potent antibiotics for managing these infections is untrue. Instead, the measures include establishment of hospital infection control committees, training of healthcare workers on infection control, and development of policies on hand hygiene. Others are development of policies on antibiotic use in hospitals and policies on medical waste management. In developed countries, much has been documented on the burden of HAI, where its prevalence is 5–15% of patients on admission in regular wards and as high as 50% or more in patients admitted to intensive care units. This shows that patients in intensive care units are at high risk of HAI. 12. a) T b) F
c) T d) T e) T
If the CTG is normal, the risk of acidosis is negligible, but 50% of pathological CTG traces are not associated with acidosis. Babies with acidaemia do not exhibit FHR accelerations. 13. a) T b) T c) T d) T e) T These time frames demonstrate the resilience of well-grown fetuses without risk factors. The obstetrician or midwife, however, does not know for sure that the baby is well grown. 14. a) T b) T c) F
d) F e) T
Total and persistent body movement characterises fetal behaviour in the first half of the pregnancy. Fetal movements diminish with maturity and the development of rapid eye movement sleep pattern. Accelerations are hard wired in fetal neurological behaviour and they occur independent of fetal movement. 15. a) T b) T c) T d) F e) T The development of intrapartum hypoxia is manifested by the development of fetal heart rate decelerations, which must provoke an increase in baseline fetal heart rate or persistent bradycardia. A normal fetal heart rate variability suggests neurological integrity and a low risk of significant hypoxia, acidaemia, or long-term neurological deficit. 16. a) F b) T c) T
d) T e) F
The MOREOB Program is delivered in modules each with a specific name. The first module is called ‘learning together’ the second module is ‘working together’; and the third module has the title of ‘changing the culture’. 17. a) F b) F c) F
d) T e) F
The inter-disciplinary ranges calculated for the pre-test results and for post test results that correspond with the completion of module three is 12%. 18. a) F b) F c) T d) F e) F The percent changes for each element tested in the Culture Assessment Survey show that the patient safety category had the biggest change at 20%. 19. a) F b) F c) T d) F e) F Other approaches without measurements, such as implementing clinical guidelines or undergoing an accreditation process, can be used to improve quality of care. Measurement, however, plays an
Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A7–A13
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important part in improving quality of care and promoting beneficial changes. New treatments and technologies are constantly emerging that have made maternal death a rare event in industrialised countries. Consequently, maternal mortality lacks sensitivity as a marker for the quality of obstetrical care. Maternal and neonatal deaths, especially in industrialised countries, have become rare and are often preventable by good healthcare. Today, parents expect not only survival of the mother and neonate, but also maintenance of good health, optimal comfort for the mother and baby, and an overall positive experience. Therefore, other quality indicators must be used. In recent years, numerous quality measures have been proposed in obstetrics. A number of national and international organisations and professional bodies have developed several quality indicators. To date, consensus is yet to be reached on the best set of measures. 20. a) T b) F c) T d) T e) T The CUSUM chart can be used as a dashboard to monitor quality indicators in maternity units. Several statistical process control have been adapted for use in medicine, including the Shewhart chart and funnel plot. An advantage of the CUSUM approach over other quality-control charts is that the entire history of the healthcare activity is considered when determining the result after each new episode of activity. This characteristic enables CUSUM charts to detect fluctuations in indicator rates that may not be evident from aggregate data analysis. For CUSUM charts, p0 (the acceptable rate) is the rate for which activity is considered ‘normal’ and no investigation is necessary. In contrast, p1 represents an unacceptable rate and indicates that an audit is needed, regardless of whether corrective action is required. 21. a) T b) F c) F d) F e) F The Delphi technique is a structured process that uses a series of questionnaires or ‘rounds’ to gather information. Rounds are held until group consensus is reached. The Delphi technique is a systematic approach in which indicator selection relies directly on the available evidence complemented with expert opinion. In the Delphi process, the participants never meet. This characteristic avoids domination of the consensus process by one or a few experts. The Delphi process permits the participation of a large number of individuals across diverse locations and areas of expertise. 22. a) F b) F
c) F
d) F e) T
The RADICAL framework emphasises the dynamic relationship between person and system. The domains in RADICAL should not be treated as silos; integration of the domains is a quintessential attribute of the framework. The framework proclaims a worldview of patient safety, emphasises the role of individuals in creating safety and the interdependence of various components of the system. Qualitative and quantitative data may be collected. Schema theory and a bionomic approach to patient safety both underpin this framework. 23. a) F b) F
c) T d) F e) T
In sepsis, blood cultures and swabs should be taken before antibiotic treatment is started but should not delay treatment. They are vital in terms of ongoing management as they provide microbiological diagnosis and sensitivity which may well alter choice of anti-microbial. 24. a) F b) T c) F d) F e) F Ampicillin and first-generation cephalosporins are equally effective in reducing postoperative endometritis. A single intravenous dose of first-generation cephalosporin is as efficacious as multiple doses of broad-spectrum agents. Anaerobic cover is only usually necessary for treatment when there is suspected infection.
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Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A7–A13
25. a) T b) T c) F
d) T e) F
About one-half of maternal deaths are avoidable, and errors in communication are a common reason for substandard care. Misinterpretation of electronic fetal monitoring is a cause for cerebral palsy attributable to intrapartum events. The risk of brachial plexus injury can be reduced with evidence-based management of shoulder dystocia. The cost of maternity claims in England is as high as all the other specialties together. 26. a) T b) F
c) T d) F e) F
SBAR, closed-loop communication, and awareness of the clinical situation, team, and patient focus, are strategies associated with better team efficiency in managing emergencies. Leaders should be the team member most experienced in the specific emergency at hand, regardless of profession or seniority rank. Although it might be useful to designate a specific team member to communicate with women, what is more important is the content of the messages. 27. a) T b) F
c) T d) F e) T
Training from undergraduate level can prevent interprofessional barriers and improve teamwork in maternity. Training should be interprofessional, for all staff, and include hybrid simulation with patient actors so that participants can practise communication skills. Formal assessment of participants has not been shown to improve outcomes. 28. a) F b) T c) T
d) F e) F
Although UKOSS can be used to undertake observational studies comparing the outcomes of different treatments, individual women are not randomised and the system cannot be used to conduct randomised-controlled trials. UKOSS can be used to monitor the effect of the introduction of a new treatment where the disease treated or prevented is rare. For example, a UKOSS study of eclampsia showed the effect of the introduction of therapeutic and prophylactic magnesium sulphate. Studies can be rapidly introduced if there are safety concerns raised about new treatments or policies; for example, a UKOSS study to measure the incidence of anaphylaxis is being conducted to address concerns about new antibiotic prophylaxis policies. UKOSS is principally designed to study rare complications that require a large collaboration to generate robust information. Common complications can be studied on an individual, hospital or regional basis. Although observational studies can provide information about the relative effectiveness of different treatments, they are not interventional studies and cannot therefore formally test efficacy. Any differences observed may be due to uncontrolled confounding, and a randomised study design is the only way to robustly account for this. In situations in which randomised trials are difficult or impossible, however, population-based observational studies may provide the highest quality evidence available. 29. a) T b) T c) T d) F e) F The data collected for UKOSS studies includes details of patient management, thus individual hospitals can use these data to assess whether their practice conforms to guidelines where these exist. The conditions studied using UKOSS may themselves be outcomes (e.g. peri-partum hysterectomy as an outcome of severe postpartum haemorrhage), or may themselves have outcomes that can be used by hospital units for monitoring purposes (e.g. hypoxic brain injury as an outcome of amniotic fluid embolism). Studies conducted using UKOSS can provide information about risk factors for individual conditions and can thus be used to identify high-risk populations. This information, in conjunction with data about the characteristics of a population served by the hospital, can be used to help design appropriate services. Although UKOSS can identify variations in disease incidence, more detailed information, such as through confidential case review, is likely to be needed to fully investigate these variations. Similarly, quality of care is better assessed with a more detailed case review process, as UKOSS data will only capture some aspects of care.
Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A7–A13
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30. a) F b) T c) F d) T e) F Uterine rupture occurs in about one in every 500 women who have had a prior caesarean section who plan vaginal delivery. Overall, 26% of women had a hysterectomy after management or refractory haemorrhage with uterine compression sutures, interventional radiological techniques, pelvic vessel ligation or factor VIIa. Maternal 2009A(H1N1) infection is associated with a statistically significantly higher risk of poor pregnancy outcomes, including preterm delivery (aOR 4.0, 95% CI 2.7 to 5.9), stillbirth (aOR 4.2, 95% CI 1.4 to 12.4), and perinatal mortality (aOR 5.7, 95% CI 2.2 to 15.1). Both Black African women (relative risk 2.35, 95% CI 1.45 to 3.81) and Black Caribbean women (RR 2.45, 95% CI 1.81 to 3.31) have a higher risk of specific severe maternal morbidities when compared with white women. Comparison of similar studies suggests that eclampsia occurs more frequently in the Netherlands and Scandinavia compared with the UK.