Patient safety in ob/gyn is facing some old and some new challenges. Ob/gyn has been a leader in the use of simulation techniques to help healthcare teams prepare for dealing with a variety of emergency situations. And many of the fine teamwork training exercises in programs such as TeamSTEPPS™ have their foundations in ob/gyn teams working together. But there are other areas where success is less obvious. Recent data (Zhang 2010) shows a continued rise in the rate of cesarean sections in the United States and the problem is not simply repeat C-sections. Now almost of third of all deliveries in first pregnancies are by C-section. There may also be an association between induction of labor and subsequent C-section. We will undoubtedly see renewed efforts to try to match labor induction and C-sections to medically appropriate indications.
But in the meantime we have seen several other important initiatives in the field of patient safety:
Patient Safety in the Surgical Environment
ACOG has announced release of a new guidance to prevent surgical errors. Committee Opinion Number 464 Patient Safety in the Surgical Environment is a set of recommendations on patient safety for ob/gyns in the operating environment but is good advice for anyone in the operating environment.
The guidance notes risk factors for wrong site surgery such as multiple surgeons, multiple procedures, unusual patient physical characteristics, and time pressures and stresses use of both Joint Commission’s universal protocol and the WHO Surgical Safety Checklist. They stress ensuring that all documents, materials and instruments are reviewed before surgery. They note the preoperative “briefing” is important for assigning roles and setting expectations. Other parts of the universal protocol include appropriate site marking and the “time out” done for patient/procedure verification just prior to surgical incision. They note other important issues (prophylactic antibiotics, DVT prophylaxis, etc.) may also be discussed as part of the time out.
Importantly, they stress a variety of patient safety principles that are not unique to surgery but remain important in the surgical environment. Medication safety is one of those. They note that medication safety is vulnerable in the OR environment because so many orders are given verbally and many of the medication safety tools we use elsewhere in the hospital (eg. CPOE, barcoding) are not usually available in the OR. The urgent pace and stresses and confusion during rapidly evolving events in the OR may further facilitate medication errors. Therefore, good communication amongst all parties and using readback/hearback are very important. They also suggest teams develop and use protocols for administering commonly used medications.
They note the importance of fatigue in creating surgical errors. This applies not only to residents, for whom formal work hour guidelines exist, but also for all participating surgeons and other staff. They note that all members of the team must be vigilant to identify fatigue in other members of the team and have appropriate backup available.
A section on retained foreign objects recommends following the ICSI protocol for avoiding retained foreign objects during vaginal surgery.
Especially important are their comments on avoiding distractions. They stress the concept of the “sterile cockpit” and recommend postponing any nonessential conversation until surgery is completed. They recommend things like beepers, radios and telephone calls be avoided if at all possible. They also suggest careful consideration be given to the presence of any nonessential personnel in the room that might be additional distractions.
The guidance also includes a section on issues related to new surgical procedures (privileges, familiarity with equipment and the procedure, presence of nonsurgical personnel, etc.).
Lastly, they note that their recommendations apply to any venue where surgery is being done – the hospital OR, an ambulatory surgery unit, or an office setting.
The MOREOB Program
The first outcomes of a comprehensive obstetrical patient safety program in Canada have been published (Thanh 2010). Multiple hospitals in Alberta participated in the 3-year long MOREOB Program (Managing Obstetrical Risk Efficiently). Severe newborn morbidity was significantly reduced and maternal outcomes (reduced third- and fourth-degree tears and reduced lengths of stay) were also improved.
The MOREOB Program focuses on communication and teamwork building, skill building, culture of safety, emergency skill drills, education, and use of patient safety tools like RCA, FMEA, near miss reviews, audits, etc.The program has reduced NICU admissions and resulted in fewer neonates with respiratory distress, sepsis, CNS hemorrhage, and a variety of other neonatal and maternal outcomes.
Peripheral Nerve Injuries During Gynecologic Surgery
We’ve done previous columns on peripheral nerve injuries related to anesthesia and surgery (see our September 29, 2009 Patient Safety Tip of the Week “Perioperative Peripheral Nerve Injuries”). This month’s Obstetric and Gynecology Clinics of North America has an excellent article on peripheral nerve injuries complicating gynecological surgery (Bradshaw 2010). It uses 9 case histories to highlight the mechanisms of injury to a variety of peripheral nerves during a variety of different gynecological procedures. Most such injuries are related to compression from either improper positioning or compression from surgical retractors. They point out the positions and circumstances that place various nerves in vulnerable positions and make recommendations for actions to avoid such injuries.
Matching Newborns to Correct Mother’s Breast Milk
In our November 17, 2009 Patient Safety Tip of the Week “Switched Babies” we also discussed the issue of newborn infants being inadvertently fed breast milk from other mothers. In that we suggested use of barcoding technology to help avert such mixups. We recently came across an article describing such a system that not only aids in identification of correct baby and correct milk but also ensures the milk being given is fresh.
Zhang J, Troendle J, Reddy UM, et al. Contemporary cesarean delivery practice in the United States. Amer J Ob Gyn 2010; 203: x-ex-x-ex (published online August 13, 2010)
ACOG press release. Ob-Gyns Issue Guidance to Prevent Surgical Errors. August 23, 2010
ACOG. Committee on Patient Safety and Quality Improvement.
Committee Opinion Number 464. Patient Safety in the Surgical Environment.
September 2010. Obstetrics & Gynecology 2010; 116(3): 786-790
ICSI (Institute for Clinical Systems Improvement). Retained Foreign Objects During Vaginal Deliveries, Prevention of Unintentionally (Protocol) 11/24/2009
Thanh NX, Jacobs P, Wanke MI, et al. Outcomes of the Introduction of the MOREOB Continuing Education Program in Alberta. J Obstet Gynaecol Can 2010; 32(8): 749–755 http://www.sogc.org/jogc/abstracts/201008_Obstetrics_4.pdf
Bradshaw AD, Advincula AP. Postoperative Neuropathy in Gynecologic Surgery. Obstetric and Gynecology Clinics of North America 2010; 37(3): 451-459
EMR-linked system matches premature babies with breast milk.
MedCity News August 10, 2010