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The acronym "OSCE" stands for "Objective Structured Clinical Examination".
The "objective" bit comes from the fact that everyone has the same exam.
And the examiners having to stick strictly to the same script.
This gets over the old problem of harsh and gentle examiners.
And different degrees of complexity when dealing with real clinical cases.
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The RCOG gives basic advice.
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More detailed advice from yours truly.
The physical layout.
The exam takes place in a large hall.
12 "stations" are arranged in a circuit around the hall.
Each station has a table and two or three chairs.
You sit on one side of the table.
The examiner and role-player, if there is one, sit on the other side of the table.
Sometimes there may be another consultant sitting in as an observer.
Each station has screens around it.
The information for the station is attached to the screens.
It is also stuck to the table.
The information consists of the "Candidate's Instruction".
This has to be read carefully, as it tells you exactly what you have to do.
Like the essays, there are no marks for doing stuff you have not been asked to do.
Any other information relating to the station will be there.
This could be a list of laboratory results, a list of patients on the labour ward etc.
Some candidates prefer to read the information and make any notes while outside the screens.
Others prefer to go in and read the information and make their notes on the table.
You are provided with a spiral-bound notebook, like those used by secretaries.
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Each station lasts 15 minutes.
The College says that one minute of that is initial reading time.
In practice, you could sit there reading for 14 minutes.
And then try to squeeze your answer in the remaining time.
No-one will stop you.
You will, of course, fail abysmally!
A bell is sounded one minute from the end of the station.
This is to give you time to finish and move to the next station.
It is vital that you keep an eye on the time.
If it is a role-play or viva station, make out a plan at the start.
This is the same technique that you would have used for the short essays.
You need to make sure that you have enough time to deal with all your key points.
Work out roughly how much time you think you should allocate to each point.
Then keep a careful eye on your watch.
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10 stations are "active stations" with an examiner or an examiner plus a role-player.
2 stations are preparatory stations.
These could be almost anything.
The College gives a number of examples:
You have 15 minutes to prepare something.
You will then discuss it with the examiner or role-player at the next station.
It could be to write a protocol, to prepare an audit, to criticise an information leaflet.
The typical one with a role-player is that she has downloaded information from the internet.
She wants to know its value in dealing with her problem.
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It is important to have a memorised model of the history you will take.
This will help prevent you missing something vital.
Remember the possibility of a "hidden agenda".
There will almost certainly be one if the station is about pre-menstrual syndrome.
And one will be likely if the topic is chronic pelvic pain or postnatal depression.
I have written possible models for history-taking:
Have a look and adapt them to your own style.
But, work hard to memorise them, so you can use them on the day.
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You didn't write your short essays without spending a few minutes writing plans.
The same applies to the OSCE stations.
You can see the "Candidate's Instructions" on the screen outside the station.
So, you know what is being asked of you before you go in.
Write out the key points as headings.
Then keep an eye on your watch to make sure you use the time sensibly.
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Think back to when you first thought of becoming a doctor.
You were full of grand notions of benefitting mankind.
Perhaps you had some experience with illness in a relative or friend that particularly motivated you.
Then consider the reality of the daily grind as a doctor.
You are so busy, so much under pressure that you stop thinking of the patients as people.
When you were young you thought that you would treat them as if they were your sister, mother, best friend and so on.
Now they are just another case and a major irritant if the clinic is running late and they are assailing you with irrelevant details.
It is important to salvage your humanity from the pressures of practice.
In real life it only takes a moment or two to demonstrate understanding of the suffering that patients go through.
"That must have been really hard."
"That must have been really horrible."
"Did you find that hard to cope with?"
"How is your mother now?"
In the event of a sister with a handicapped baby, ask: "how is the baby now"?
"How is your sister coping?"
In the exam it is important too.
It makes the role-player realise that you are a kind and caring doctor.
If she likes you, it helps make the role-play go more smoothly.
And there might just be a mark in response to the question: "is this a doctor you would consult again"?
You should make it part of your routine practice to include some remark along the lines above.
Then it will be second nature in the exam.
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Sometimes there is sense in quickly rattling off all your headlines at the start.
This means that you are sure to "tick" some of the examiner's boxes.
For example, with a role-player and a station about Down's syndrome you might say:
"first of all I am going make sure you have all the information you need about Down's syndrome
Then I am going to explain the tests we can do.
etc. etc.".
You might forget one of your headlines during the discussion or run out of time.
You could still get some at least a mark for mentioning it in the headlines.
Similarly, in a station about writing a protocol you might dash off a dozen headlines.
Then fill in the detail.
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Have a prepared, standard introduction for the role-players.
This is dealt with in "Communication skills".
Start practising right away with patients in clinic.
Then it will be routine for you in the exam.
What if you are working outside the UK and your patients don't speak English?
It is all the more important to practise!
Get hold of friends, colleagues, family who speak English.
Practise your introduction until it trips off the tongue with ease.
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Use good communication skills.
It is vital to communicate well.
Use simple words and sentence construction.
Avoid medical jargon.
Look at the role-player.
This is covered in detail in "communication skills".
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Empty your head after each station.
It is important to forget each station as soon as it is over.
Don't carry it with you, half thinking of what you might have done better.
This will just distract you from the next station.
This is one of the main benefits you get from going on a course - it gives you the chance to practise it.
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You have fifteen minutes to tell the examiner what you know about a subject.
Often they just tell you what they want you to talk about.
"Tell me the current thinking on the use of HRT."
So you have to decide what to put in and what to leave out.
But they might have two or three questions to ask you to give more shape to the station.
On Fragile X syndrome the viva might be in three parts.
The examiner is not allowed to help you in any way.
This is part of the "objectivity" of the exam.
Elderly male examiners might be disposed to be more helpful to beautiful young female candidates than their male counterparts.
So, no prompts or indications of how well or badly you are doing can be given.
This makes it a really stressful activity.
And something you have to practise over and over.
Get a friend or relative to be the examiner.
They sit with no expression and say nothing for the whole viva.
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Some aspect of clinical governance is likely, so you have to know the topic well.
You could be asked for an overview of what clinical governance is and what it is for.
There is detailed information here.
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In an ideal world, patients would only derive good from their encounters with health services.
We would be perfect ministering angels, just like we imagine ourselves to be!
There would be no adverse incidents: drug reactions, surgical misadventures etc., no complaints and certainly no legal cases.
Sadly, the real world is different.
We make mistakes.
Things we did not want or plan occur to the detriment of patients or staff.
Risk management is the process whereby we reduce the number of (ideally eliminate) such adverse incidents.
And minimise their consequences when they do occur.
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The report "An Organisation with a Memory" (OWAM) was published in June 2000.
It triggered much of the development of risk management in the NHS.
The report was by an expert group chaired by the Chief Medical Officer, giving an indication of how seriously the subject was regarded.
It was mainly about adverse events in the NHS and how we might learn to do things better.
It noted that serious adverse events were uncommon but a major problem for those suffering them and a gigantic cost to the NHS.
It highlighted the fact that:
“such failures often have a familiar ring,
displaying strong similarities to incidents which have occurred before
and in some cases almost exactly replicating them.
Many could be avoided if only the lessons of experience were properly learned”.
Vincent et al in the 2001 paper mentioned above judged that about half of adverse incidents could have been prevented by “ordinary standards of care”.
Schiff et al found that doctors were prepared to give accounts of their personal diagnostic errors.
Almost 70% of the errors were rated as of major or moderate significance.
So they did not appear to seek to hide serious mistakes and only acknowledge those that were inconsequential.
They concluded:
"This readiness suggests that diagnostic error is not unusual in clinical practice,
and actively soliciting such cases represents an opportunity for tapping into a hidden cache of medical errors
that are not generally collected by existing error surveillance and reporting systems."
Schiff G, et al "Diagnostic error in medicine" Arch Intern Med 2009; 169: 1881-87.
The scale of the problem necessitating risk management.
The DOH's publication: "An Organisation with a Memory" of 2000 gave an indication of the problem.
The authors of OWAM reckoned that adverse events affect about 1 in 10 of those admitted to hospital.
Vincent et al agreed, putting the figure at 10.8%, with about a third leading to death or moderate or worse disability.
These are horrifying figures and much higher than I would have volunteered as a guess if I had been asked.
OWAM put the consequent additional costs just from the extended stays in hospital at £2 billion per annum.
If you add the costs of loss of earnings, sick pay, compensation etc. and it is easy to see that this is an enormous problem.
Further figures in the OWAM report noted that each year:
400 people suffer lethal or serious adverse events involving medical devices,
about 10,000 people have serious adverse reactions to drugs,
about 1,150 people commit suicide despite recent contact with mental health services,
nearly 28,000 written complaints are made about clinical treatment in hospitals;
clinical negligence claims cost around £400 million,
hospital acquired infections, of which about 15% may be avoidable, cost about £1 billion.
Its conclusions were:
· Information on the frequency and nature of adverse events in the NHS is patchy
and can do no more than give an impression of the problem.
Information from primary care is particularly lacking;
· International research (including a recent UK pilot study) has thrown light on the potential scale of the problems,
and suggests that these may be around 850,000 adverse events each year in the NHS (range 300,000 to 1.4 million);
· The financial costs of adverse events to the NHS are difficult to estimate but undoubtedly major - probably in excess of £2 billion a year;
· There is evidence of a range of different kinds of failure, and of the recurrence of identical incidents or incidents with similar root causes,
· Case studies highlight the consequences of weaknesses in the ability of the NHS as a system to learn from serious adverse events;
· There is a need for further work focusing specifically on how the impact of adverse events on patients, their families and staff can be minimised.
Dr. Cook, with whom I worked in Stockport, reviewed the subject in 2000.
He found reported incidences of adverse events in hospitalised patients:
from 3.7% in the Harvard Medical Practice Study in the United States
to almost 16% in the Quality in Australian Health Care Study.
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How do we "do" risk management?
We start off by trying to identify all the adverse incidents that could occur which would entail:
finding out all the adverse incidents that have ever occurred
look at data from:
the RCOG,
the National Patient Safety Agency,
the Medical Defence Union.
make sure that all adverse incidents within your system are recorded systemically
check all complaints
check all legal actions
imagining all the adverse incidence that could possibly occur.
Then we deploy effective defences to ensure that we are invulnerable - the Ronald Reagan missile shield philosophy.
But, being pragmatists, we know that some bad stuff will occur.
This means we need a back-up plan to minimise the consequences of adverse incidents we did not foresee or that arise through error or misadventure.
We need a system that allows staff to report incidents immediately so that remedial action can be taken.
This means the system has to be open, non-punitive etc.
And we need to incorporate the data from these incidents into the reporting system.
So we set up a system where:
every adverse incident,
or incident that could have become an adverse incident (a “near miss”),
is reported and analysed.
The analysis identifies the cause(s) of the incident or near miss and leads to fortification of the defences.
Vigilance in reporting adverse incidents and their first cousins, “near misses”, means that we are dynamic and abreast of changing circumstances.
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One of the “buzz words” you need is “root cause analysis”.
This has the tang of the tedious, boring, management-speak that immediately induces:
somnolence,
a brisk desire to become a philosopher or a gardener
or to move on to something really interesting like picking ones nose and scrutinising the results.
But bear with me! I write this in November 09 after a weekend in Scotland at a family wedding.
We stayed with long-time friends, Hugh and Sheila.
On the morning after the wedding Hugh showed me an article in the Glasgow Herald.
A woman had been admitted for mastectomy and reconstructive surgery in a prestigious Edinburgh hospital.
Fit and healthy (apart from breast cancer) she died of haemorrhage on the night of the operation.
The family were devastated and bemused.
How could such a disaster have taken place after routine surgery in a major teaching hospital?
A drain was inserted into the operation site, but no records were kept of the volume drained in the afternoon after the operation.
Other records, like pulse and BP, apparently, were not what they should have been.
Her haemorrhage was not detected until the evening, when the best efforts of the rescue posse were unavailing.
Worse still, the nurse in charge of the patient, who had failed to keep adequate records, had then falsified the records in an attempt to cover her failures.
“How could a professional person behave in this way?” my friend asked.
She had failed to look after the patient adequately and had then dissembled to protect her own miserable hide.
Hang, draw and quarter, I say!
The only apposite punishment.
This is where root cause analysis comes in.
If we just shoot the nurse and content ourselves that we have dealt with the matter, we may have missed the real cause or causes of the disaster.
Not, “take her out and torture her to death for causing the woman’s death”.
But “how on earth could a presumably competent and caring nurse behave so deficiently?”
And don’t be so presumptuous to believe that you would not be tempted to falsify records to exculpate yourself from blame!
You might not subscribe to the Gospel of John.
But the phrase "Let him who is without sin cast the first stone" is apposite, whatever our faith or lack of it.
Did she have the training and experience necessary for the tasks she faced?
Were there enough nurses on duty?
Had financial cut-backs led to dangerous staffing levels?
Had two colleagues reported sick and not been replaced?
How many other seriously ill patients was she caring for?
Were there other issues distracting her?
Had there been a medical emergency?
Was there an aggressive husband threatening violence for perceived mismanagement of his wife’s care?
Was there a blockage in the toilets meaning that she had spent an hour on the phone trying to get the plumber to come to effect a repair?
This might be a latter-day Mother Teresa placed in an impossible position, not a murderous psychopath or total inadequate.
This is root cause analysis!
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I hope that the information on this website will give you the basics.
Perhaps even enough for the exam.
Nonetheless, I'd be inclined to read at leas the first three of the following documents / websites.
You must read this! It was first published in 2001 (timing derived from the DOH publication “An Organisation with a Memory”, discussed below).
It was updated in 2005 and again in 2009.
This frequency of updating is unusual for an RCOG document, reflecting the importance now given to risk management.
2. The WHO surgical safety check list.
This is a way of introducing airline-type checklists into surgical practice.
Essential to know about it for the MRCOG: Visit the National Patient Safety Agency.
See the section on the WHO check list on this website.
3. "Maternity Dashboard". RCOG’s Good Practice. No 7. .
The unit decides the things it needs to monitor .
The completed card allows "at a glance" assessment .
Which things are OK, which are borderline and which need attention.
There is an expectation by the RCOG that all units will adopt it.
It is a simple concept, but best understood by seeing an example.
The best thing is to have a look at the illustration on the RCOG website.
4. “Reducing risk on the labour ward.” Strachan. TOG. 2005 7: 103-107. Read this!
4. “Risk management in obstetrics.” Walker. Recent Advances in O&G. 23. Read this!
5. “How to investigate and analyse clinical incidents.” Vincent et al. BMJ 2000; 320:777-78.
6. “Risk management in O&G.” Pateisky. Recent Advances in O&G. 24.
Read this! Good, sensible advice that gives you a flavour of what this is all about.
7. “Human error. Models and management.” Reason. Reason. BMJ 2000: 320: 768-770.
If you find a professor of psychology called “Reason”, you have to treat him as a guru, become an avid fan and read everything he has written!
It is a useful document that spells out the differences between the person and system approaches.
8. “Adverse events in British hospitals.” Vincent et al. BMJ 2001; 322: 517-519 (3 March)
This is an analysis of adverse events noted in 1014 medical and nursing records from 2 London hospitals.
The incidence of adverse events was 10.8%, with an overall rate of adverse events of 11.7% when multiple adverse events were included.
About half of these events were judged preventable with ordinary standards of care.
A third of adverse events led to moderate or greater disability or death.
9. National Patient Safety Agency publications.
10. "Safe Births" Kings Fund 2008.
11. Healthcare Commission. “Towards Better Births.” "Towards Better Births".
12. “Saving Mothers’ Lives.” Maternal Mortality Report.
Its ten top recommendations include advice about ensuring that lessons from adverse incident analyses are fed back to all relevant staff.
13.
TOG has an article: 2005;7: 103 - 107.
Much of it is taken from: "Human error: models and management" BMJ 2000;320:768-770.
This was written by James Reason, Professor of Psychology: his name ought to make it essential reading!
It is a good article which outlines the "how and why" of moving to analysis of systems rather than individual errors.
And underscores getting to the real reasons for errors happening, "root cause analysis".
And another good article in the BMJ by Vincent et al:
"How to investigate and analyse clinical incidents: Clinical Risk Unit and Association of Litigation and Risk Management protocol".
BMJ 2000;320:777-781. http://www.bmj.com/cgi/content/full/320/7237/777
If you get through all of
this, you will be pretty comfortable in the exam!
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Adverse incidents & near misses.
complaints patient satisfaction survey legal suits
confidential inquiries
National Patient Satisfaction Agency http://www.npsa.nhs.uk/.
Risk management is about trying to stop things going wrong and maximising safety.
This could be anything from clinical errors to the roof falling in.
It is a vital part of clinical governance and goes hand-in-hand with optimising clinical practice.
For the exam we are talking about clinical risk, i.e. risk to patients.
But we need to remember risk to staff.
Our professional ethos should include great attention to risk management.
But, if we are lackadaisical, CNST is a powerful motivator.
It is often thought that risk management is about reducing complaints and litigation.
This is not a primary goal, though good clinical risk management will be effective in this regard.
History of risk management in the NHS.
We have always had informal risk management in clinical practice.
The consultant would discuss with a new registrar when to phone for advice or help.
And which procedures they were allowed to tackle on their own.
The DOG published "An organisation with a Memory", "OWAM" in 2000.
This detailed risk and its impact on patients in real life.
OWAM gave rise to “Building a Safer NHS for Patients”.
It noted:
“In the past, most health services around the world have underestimated the scale of unintended harm or injury experienced by patients as a result of medical error and adverse events in hospitals and other health care settings.
There has been no real understanding of the approach necessary to reduce risk to patients based on analysing and learning from error and adverse events”.
But it went on to say: “This is changing.
The whole issue of patient safety, medical error and adverse event reporting is becoming a high priority in health care systems in this country and across the world”.
Despite this the HealthCare Commission undertook a review of maternity services in 2007.
Its report "Towards Better Births", was published in 2008.
It noted that 21% of maternity departments were in the "least well performing category".
I.e. in need of serious improvement.
Key concerns were:
levels of staffing in some trusts that were below average and possibly inadequate
consultants not spending the recommended time on the labour ward
inconsistent attendance at training sessions by doctors and midwives
poor continuity of care
antenatal recommendations not followed, especially in high-risk pregnancies
poor communication and support for recently delivered mothers
too few beds and bathrooms on labour wards
poor data and IT systems prevented efficient service management.
In an ideal world you would:
know every possible risk
and have perfect means of anticipating and preventing them at your disposal.
But we don't live in an ideal world.
So, we face the task of trying to identify every possible risk.
We need to:
identify every risk that has ever occurred,
be able to imagine every other thing that might go wrong,
But, however clever we are, we will miss things.
Incidents will still happen that cause harm or could have caused harm.
To learn from these and create appropriate defences we need to:
record everything that did go wrong,
record all "near misses": things that nearly went wrong, but no-one came to harm
and be able to take steps to eliminate all the associated risk:
create defences,
inform the staff about these newly-identified risks and train them in the best ways of dealing with them..
You need to be able to prioritise:
There are too many risks for us to be able to draw up plans for all of them.
To prioritise, there are three main considerations:
how dangerous would the event be?
how likely is it to happen?
what resources would need to be deployed to prevent it?
You might be a science fiction enthusiast and be concerned about asteroid strikes on the hospital.
Such an even would be catastrophic, but it is somewhat unlikely.
To prevent it you would need some kind of missile shield.
This would involve resources beyond those of the average Trust!
But reducing the risk of fetal and maternal damage from shoulder dystocia could simply mean better staff training in anticipating and dealing with it.
Risk management is an essential part of CNST, the basics of which you need to know.
Read this useful outline from NHS Scotland.
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Viva: adverse incident reporting.
This, like so many other things, is obvious once you know what it is.
Stuff happens, as they say.
I.e. things that were not planned and could have led to bad outcomes.
We are particularly interested in clinical matters.
But there are other big issues.
What if the hospital's power supply fails?
Will the back up systems of generators etc. kick in efficiently?
Are key areas and equipment like operating theatres, intensive care units and neonatal ventilators protected?
In the clinical arena there are adverse incidents and "near-misses" where the situation is usually salvaged and no one comes to harm.
But we should learn from them and take steps to prevent them recurring.
You need a "no-blame" culture so that people are encouraged to report incidents.
You then need a system to investigate them and reach conclusions.
This would normally be done through the Risk Management Team.
It would also be their job to feed back what has been learned and recommended to all the staff involved and to those planning and running the service.
If a piece of equipment malfunctions under certain circumstances, you want all the staff who use it to know about it.
But you also want the planners and managers to do something about replacing or upgrading it.
There is a nice explanation with a pictorial diagram for those who find them helpful here.
And a good summary from the MDU.
The Maternal Mortality highlighted the need for us to learn lessons from past experience.
It particularly pointed out that the whole risk management business may be carried out, but nothing be fed back to the workers.
This makes the exercise futile.
Except for the managers, who can say that it has been done and thus tick all their boxes necessary to get their bonuses!
The authors of the Report saw it as important enough to make it number 7 in their list of "Top Ten Key Recommendations".
The Top Ten Key Recommendations could easily be a viva station, so make out a card and learn them!
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Risk management: write a report.
I think you would probably have a preparatory station to gather your thoughts.
But I would not rely on it and you should make sure that you have prepared this station.
1. First of all, who has asked for the report?
What is it to be used for?
Don't write reports unless it has been requested by the Risk Management Committee.
2. What kind of report is wanted?
There are two main types:
(a) a factual summary with no assessment / commentary.
these are quite difficult as you are always tempted to include opinions.
you would not state that the documentation was poor because the writing was poor, the date gave the month, but not the year etc.
you would state the facts: in places (give page numbers as examples) you could not read the writing
the dates were recorded with the day and month but not the year.
(b) a factual summary with your views on what appear to be deviations from ideal practice.
e.g. protocols not being used in a timely fashion or being altered without explanation or authority from the consultant
remember that the key analysis is the "root cause analysis"
this will entail someone senior interviewing everyone who was involved, including the patient and her partner
all your report is going to do is to highlight areas where the management seemed substandard
you are not writing the definite judgement, so don't get carried away.
you might write:
at 16.00 on ..... the patient was noted to have had a PPH in excess of 1,500 ml.
the protocol for PPH is normally triggered by a blood loss of 500 ml. or more.
in this case the protocol was not triggered and the consultant was not informed.
the protocol stipulates that a baseline clotting screen should be performed with the initial investigations.
in this case no clotting screen was done.
you are recording deviations from what one would expect the practice to be, but not trying to decide why they happened.
3. Give your details:
full name,
grade and how long in post,
all medical degrees and years acquired,
courses attended and dates e.g. basic surgical skills, ALSO, laparoscopic surgery level 1, etc.
any particular skills relevant to this case: e.g. an MD written about the management of PPH.
4. Record who asked you to write the report and why.5.
5. Note the type of report requested.
6. Give the timescale.
7. When writing the report, number all the paragraphs.
8. It is usually useful to give a brief summary of the key facts.
9. Then a "blow-by-blow" account of what happened.
10. Have the report typed.
11. Ask a colleague to check the report for typos and obvious errors.
12. Submit two copies of the report and keep one for your records.
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You can find information about consent here.
This is another subject you need to know well.
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This is basic stuff.
And another subject you need to know well.
If your unit has a training package, go through it shortly before the exam.
If it doesn't, have a look at this one.
You need to be familiar with modern terminology and concepts.
And have some clue about acid-base balance.
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Viva: Maternal Mortality Report.
I reckon that there are two main types of questions:
one relating to the clinical facts
definitions,
main causes of direct and indirect deaths,
and another about the ten key recommendations.
You should know the clinical stuff from the written exam.
The ten key recommendations should be on a card, as some of it does not immediately come to mind.
It would make for a wonderful viva if you knew the topic and a nightmare if you did not.
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Another station that is best thought about in advance.
What are the key things you would do on such a ward round?
Make out a card!
Then apply this to the problems posed by the station.
I would suggest:
make sure you have read the notes carefully
make sure you know exactly what surgery is proposed
taking particular care if it is a unilateral procedure like oophorectomy
and knowing the possible complications you should warn about
especially if these are in a RCOG document, these being available here
introduce yourself
check you have the correct patient
check that she has been listed for the correct procedure
i.e. that the operation for which she is listed is the one she understands that she is to have
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WHO in-theatre safety check list.
The WHO launched a Surgical Safety Checklist in 2008.
It is a simple concept, drawn from high-risk industries like air travel.
We know that pilots have a standardised pre-flight check list.
Now theatres have one too, covering pre-surgery, the operation and post-surgery.
The NHS has signed up to its implementation and all hospitals are expected to use it.
It has three main parts:
You can guarantee that It is another topic that is going to crop up time and again in the exam.
A bit like "protocol", "audit", "fire drill" etc., it needs to be on your list of "buzz-words.
The background is the horrendous number of patients coming to harm from adverse incidents, many of which are avoidable.
135,247 adverse incidents were reported in 2007, just in England and Wales.
Some were fatal and many were potentially avoidable.
A National Patient Safety Agency has been established in the UK.
It is responsible for the National Reporting and Learning Service among other things.
It hopes to record all adverse incidents and report the data and, more importantly, potential lessons back to staff.
The National Patient Safety Agency has produced two good videos.
If you are not well-versed in the SSC, I would advise looking at both videos a couple of times.
They give a very good feel of how the checklist is done.
Video: how to do the surgical safety checklist.
Then have a look at the elements of the SSC.
You can find it here: WHO surgical safety list: chart.
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WHO in-theatre check list: "sign in"..
This has to be done by a nurse and anaesthetist at a minimum.
This is about checking;
the patient's identity,
the procedure she understands is to be done,
the side of the body, e.g. left oophorectomy, and that the site has been marked, if appropriate,
the consent that has been obtained,
for allergies.
Then technical stuff:
is the anaesthetic machine ready for action?
are intubation problems anticipated?
what blood loss is anticipated?
is the pulse oximeter attached and working?
I am surprised that there is no mention of drugs that could be problematic: antihypertensives, anticoagulants etc.
Return to WHO in-theatre safety check list.
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WHO in-theatre check list: "time out".
"Time out" means having a break from ones activities.
The idea here is that the theatre staff have a short break immediately before "knife to skin".
If gives a final opportunity to check that everyone knows exactly what is going to be done.
1. Have you done the basics: checked the patien'ts identity, the operation to be done etc?
2. Have you anticipated problems, both surgical and anaesthetic, and prepared to deal with them?
3. Have you done your routine prophylaxis - antibiotics, anticoagulants?
1. Checking the basics.
The person in charge of the checklist will ask everyone present to:
confirm the identity of the patient,
the operation to be done,
the side to be operated on - right or left.
If the patient is not asleep, they are expected to chip in too.
2. Anticipating problems.
The anaesthetic, nursing and surgical teams are asked to identify any anticipated problems.
In most cases it will be possible to state that it is a routine procedure with no anticipated problems.
If problems can be anticipated, the steps necessary to deal with them need to be discussed.
Common problems would be bleeding, possible organ injury, e.g. if there are adhesions and so on.
Availability of equipment, blood products etc. to deal with the problems should be checked.
Anaesthetic problems could relate to factors like obesity.
But also to complications from co-existing pathology:
hypertension, arrhythmia or other cardiac problem,
lung disease,
diabetes,
sickle-cell disease, thrombophilia etc.
Or from drugs:
allergies,
hypotensives,
anticoagulants,
insulin etc.
Addtional personnel may need to be available.
E.g. a bowel surgeon in cases of laparoscopic surgery to deal with dense endometriotic disease in the pelvis.
In this case confirmation would be needed about:
bowel preparation having been done,
the availability of the surgeon having been checked.
3. Checking everything is ready for the operation:
Is all the necessary surgical equipment ready and sterilised?
Is all other equipment available and working?
laparoscopy monitors, X-ray machines,
diathermy etc.
Is the necessary extra equipment available to deal with anticipated problems?
4. Prophylactic routines.
If antibiotics are needed, they should be given in the hour before surgery.
This needs to be checked.
What thromboprophylaxis is needed and has it been arranged?
compression stockings, positioning, drugs.
Return to WHO in-theatre safety check list.
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WHO in-theatre check list: "sign out".
This is done at the end of the operation.
Before the surgeon, and, ideally, other key players, have left the room.
1. Confirm the procedure that has been done.
This may be different to what was planned.
Everyone needs to be aware of exactly what has been done.
2. Confirm that a full count has been done:
instruments, needles, swabs etc.
3. Confirm that any specimens are properly labelled.
This check should ensure that:
labelling has been done correctly
name of patient,
nature of the specimen etc.
the specimen is in the appropriate medium e.g. formalin.
4. Are there any issues relating to equipment?
This could be anything from non-availability to things breaking down.
The steps to prevent the same thing happening again need to be identified.
5. What about recovery etc.
The plan for recovery and subsequent management should be agreed.
Return to WHO in-theatre safety check list.
Go to the bottom of the page and other links
Go to the bottom of the page and other links
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