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MRCOG PART 2 SBAs and EMQs

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Essay 275 - Risk management

Posted by Shachi M.
Shachi

(a) How would you classify this incident and why? [2 marks].

This incident should be classified as near miss because the diagnosis of a ectopic pregnancy was either missed or ignored at the initial presentation, putting the patient’s life at risk. This patient could have died before she even made it to the hospital, the second time.

(b) Which information would you obtain from the medical records? [9 marks]

The information to be obtained from the medical records is, the time of presentation of patient to the hospital, the time of her review and the grade of the person who reviewed her (nurse, senior house officer, registrar or consultant). One should find out if she showed any signs of haemodyanamic compromise (tachycardia and/or hypotension) or if she was symptomatic (abdominal pain, shoulder tip pain or vaginal bleeding) of a ruptured ectopic pregnancy. One should find out if she had any investigations (betahCG, ultrasound, full blood count) and if the investigations suggested a diagnosis of ectopic pregnancy. If she had signs of ectopic pregnancy (hypotension, tachycardia, tender rigid abdomen) was she advised admission to the hospital. If yes, did she decline admission. If the patient declined admission was she explained the risk (including death) of a ruptured ectopic, and was senior involvement requested. If the patient was stable and asymptomatic and ectopic pregnancy was suspected, there should be documentation in the notes that she was advised to come in if she developed symptoms (abdominal pain vaginal bleeding, dizziness, faintness, shoulder tip pain) and supplied with the necessary phone numbers to contact in case of emergency.
The quality of documentation should be noted. The documentation should be accurate, and each entry should be dated and signed.

(c)Which additional information would you require for your investigation? [4 marks
Information relevant to this case is, the results of investigations (ultrasound, betahCG), other events taking place on gynaecology emergency at the time of patient’s initial presentation (a collapsed patient takes priority over an asymptomatic suspected ectopic), bed situtation on the gynaecology ward at the time, staffing issues (people are more likely to make mistakes if they have to deal with excessive work load due to inadequate staffing). It is important to know if the training for all new senior house officers and nurses is in place and if there are accessible local guidelines for management of early pregnancy problems.

(d)What are the possible outcomes of your investigation? [5 marks].
The possible outcomes of this case are missed diagnosis of an unruptured ectopic (inadequate information from investigations or inadequate understanding of the results of investigations), missed diagnosis of a ruptured ectopic, (fail to recognise signs of rupture) failed communication (where patient failed to understand the implications of diagnosis and information given to her) or system failure (inadequate staffing, faulty ptotocols).
Posted by Srivas  P.
(a) This is an adverse event and should primarily initiate incident reporting. Very rarely it may qualify to be called as a Serious untoward incident (SUI) if the chief executive of CRM team feels there is serious mismanagement of the case and is likely to attract media attention or legal claim or if the woman dies subsequently.

Here the diagnosis is clearly missed as she had presented merely 24 hrs earlier and if the pregnancy was detected but not localized she should have been admitted for admission, followed up and had consultant review.

(b) I will find out the reasons and time of at which she presented as emergency to Gynecology clinic. What were her complaints then? I will see if her menstrual history was taken-history of any missed period and LMP, whether previous menstruations were regular. Did she have any morning sickness or vomiting suggesting early pregnancy? Any history of bleeding P/V, fainting attacks or lower abdominal pain suggesting possible ectopic pregnancy?

Did her past history suggest a high risk for ectopic pregnancy: infertility, previous PID or having multiple sexual partners? Did she have any complaints suggesting any medical or a surgical cause like appendicitis? Was surgical or medical consultation taken before she was discharged?

I would see if a preliminary pregnancy test was done if she presented with delayed periods or lower abdominal pain. I will see if any USG was done. I will review her general examination, P/A, P/S and P/V findings. Was her pulse and B.P steady and normal? Did she have lower abdominal guarding, rigidity, tenderness and any fullness? Did P/V examination suggest signs of pregnancy, any cervical tenderness or adnexal masses?

Was she asked to get admitted for observation and was Beta HcG ordered? Was she told about need for admission for observation and review by consultant especially if there were doubts about possible PID or an ectopic Pregnancy? I will see if there is any record of her being told this and also whether she refused admission and signed and went home on her own responsibility. Were the risks to her documented by concerned doctor and signed?

(c) Was it an EPAU or emergency of a hospital? Did the clinic have facility for emergency B-HCG and facility for TV USG? Is it manned by mid wife only and did she ask for review by Gynecologist? If she was seen in hospital emergency, was she seen by SHO/Registrar or consultant? Were there several emergencies at that time and was she attended to immediately? Did she have to wait for consultation? Does the unit have protocol for managing such patients and was it followed? Was she advised admission and were beds available? Was she told about risks to her if she refused admission which may include even death?

(d)Maybe there were human errors which could be because where known guidelines or protocols are not applied or there was a mistake in not applying the known protocols correctly. There could have been problems because the consultant was busy in OT and could not see the patient the first time. Are such cases handled by the right person and is the referral system well streamlined? CRM team should analyse the findings and give solutions on priority basis depending on frequency and severity of such lapses. This will help prevent future adverse events.
Posted by Manoj M.
(a) This is a gynaecological clinical incident of missed diagnosis of ectopic pregnancy leading to a critical incident to the involved patient.
This is a life threatening condition and if suspected or diagnosed could have prevented or minimised the critical incident from happening.

(b)Details from the notes regarding the initial visit, if it was documented or not, if it was documented was it properly documented with clear dates and timings and details of who had seen the patient because this is crucial for medicolegal aspects.
Details of documentations of where the patient was seen and who saw the patient and what grade of expertise was involved in decision making.
Details of history taking, examinations and investigations carried out and what was the initial diagnosis made and what was told to the patient of the findings.
Documentations regarding what was the outcome of the initial visit and plans and what did the patient do for the same, was admission suggested to her or follow up organised or did the patient refuse admission or discharge against medical advice, this would suggest if necessary actions was done rightly at the time of initial visit or not.

(c)If details are not available from the medical records a statement from the patient regarding details of initial visit and the the outcome of the same.
A statement from the medical professional team regarding the initial visit and outcome.
Details of investigations done could be collected if not avaiable from medical records.
Was her care managed according to an available hospital protocol.
Was there any clinical negligence of care which needs higher input and reporting to higher authorities.

(d)Possible outcomes are the patient was very well on presentation and an ectopic pregnancy was not suspected.
The carer was not properly trained or was ignorant of potential complication of ectopic pregnancy.
The patient choices or a differed admission could have led to the incident.
From this learning exercise a proper adherance of hospital protocol/ revision of hospital protocol could be done.
Professions could be trained properly with adequate teaching and prevent/ minimise this from happening again.
Added emphasis for proper documentation for medicolegal purposes.

Posted by g.b. D.
a)How would you classify this incident and why? [2 marks].
This incident can be classified as error in clinical assesment(which includes diagnostic scans tests and assesment)
This is because the patient had presented to emergency just 24 hours back and was seen and discharged.
There seems to be an error in assesment. either the examination findings , scan findings or test reports were not interpreted properly.
There is another possibility.If she was given enough time and assesed by a well trained person and ultrasound failed to diagnose a extrauterine sac or early/ small hemoperitoneum, then it can be classified as error of medical equipment.



(b) Which information would you obtain from the medical records? [9 marks].
I will obtain information regarding the patients history and findings and regarding details like who saw the patient, clarity of documetation made and advise given.
I will check the presenting time.whether it was a duty change over time or an odd hour.
I will check her presenting symptoms and their severity.
I will note her menstrual history ,lmp, past history of any infertility treatments, previous factors like past ectopic were present in the patient and if the same have been noted.
I will note whether general and pelvic examination was done and what were its findings.whether the investigations -upt, beta hcg, hb, blood group sent,when did the reports arrive and whether the patient waited till then.
was a transvaginal scan done.what were its findings.i will check the what diagnosis of treating doctor and whether admission was advised.
I will note the advise given regarding follow up and when to report to hospital.
I will note the documentation of these findings in case sheet.




c) Which additional information would you require for your investigation? [4 marks].
I would like to know if the was patient seen by a doctor in unfamiliar surroundings like a new locum doctor.
or if he was overworked like if there were too many admissions at that time.whether the examining doctor received any other emergency call at the same time.
.Whether a senior consultation was sought regarding the matter.
I would check if the patient seen according to hospital protocol for early pregnacy assesment.
I will check who did the scan.whether his level of training was adequate to rule out ectopic pregnancy.
I will check if the gynac ward full.
I will check if the patient was offered admission and if she refuse admission.
I will note if the patient was given an idea that there is a possibility of ectopic pregnancy and to rport immediately if certain symptoms occur.
whether the patient had a language problem and if she understood the given advise.


d) What are the possible outcomes of your investigation? [5 marks].
the possible outcomes are that the ultrasound findings were misinterpreted.
It was a cornual pregnancy and it looked like a intrautering (eccentric) sac and was reasured that there is a intrautering pregnancy.
The patient had taken treatment for infertility and a heterotropic pregnancy existed and such a rare diagnosis did not come to the doctors mind.
hence periodic trainingss have to be carried out for upgrading level of skills of doctors.such traing issues should be looked into.
the doctor was overworked and some finding slipped out of his mind. the doctor patient ratio should be maintained in each hospital and staffing issues need to be addressed.
seniors were busy to be consulted.
there was no local protocol to assess the early pregnancies in that hospital. local protocol with important areas to exclude and important advise to be given to the patients should be made.
the patient did not listen to the advise and went against medical advise. counselling and advise should be given more time and to be done by staff trained in such areas.
ther is a possibility that patient had a low understanding about english and did not understand the gravity of situation and hence issues related to interpreters need to be addresed.
Posted by Manoj M.
A 30 year old woman attended the emergency gynaecology clinic and was assessed and discharged. Twenty four hours later, she collapsed at her GP surgery and was brought in by the ambulance service. She underwent an emergency laparotomy for a ruptured ectopic pregnancy and received 10 units of blood, 6 units of platelets and 6 units of fresh frozen plasma. She was transferred to the intensive care unit. You have been asked to undertake a critical incident investigation. (a) How would you classify this incident and why? [2 marks]. (b) Which information would you obtain from the medical records? [9 marks]. Which additional information would you require for your investigation? [4 marks]. What are the possible outcomes of your investigation? [5 marks].


This incident would be classed as a near miss as there is a high risk of severe morbidity and mortality associated this incident. The patient may have been compromised severely or could have died even before the surgical intervention.

Detailed analysis of the events from the medical records is essential. The date at which the patient first presented and the reason with which she presented should be noted. The grades of the doctors who have seen and examined her is necessary as very junior doctors may not have had the experience. Any senior input, whether from a consultant level should be noted. Any previous ectopics or risk factors that were noted during the consultation. The time at which the patient was seen – whether early hours of the morning or late night should be noted. Coincidentally if the ward was busy during that time her findings may have been missed . The ultrasound findings and the BHCG results should be considered and they should be correlated with the protocols. The symptoms of the patient and the examination findings should be noted. The reason the patient was discharged and whether she was given any particular advice at discharge i.e open access and follow up should be noted. Documentation regarding patient’s wishes is necessary as patient may have taken her own discharge inspite of being warned.

The protocol of the unit is necessary to compare the care given to the patient. A statement of explanation from all the medical personnel involved is necessary. The national guidelines to compare the local protocol to look for any pitfalls in the local protocol. The training given to the doctors and the level of supervision that they have. The general influx of patients and whether staffing is adequate to offer care for the patient’s.

The possible outcomes could be from the medical side due to misinterpretation of results thereby giving wrong advice. Inadequate training for the doctors could be a reason for this. Secondly failure of communication, the patient failing to understand the advice given and not using the open access. Thirdly failure of the system to plan for any pitfalls in the protocol
Posted by Ephia Y.
A 30 year old woman attended the emergency gynaecology clinic and was assessed and discharged. Twenty four hours later, she collapsed at her GP surgery and was brought in by the ambulance service. She underwent an emergency laparotomy for a ruptured ectopic pregnancy and received 10 units of blood, 6 units of platelets and 6 units of fresh frozen plasma. She was transferred to the intensive care unit. You have been asked to undertake a critical incident investigation.
(a) How would you classify this incident and why? [2 marks].

The incident is classified as a critical incident because of missed diagnosis of ectopic pregnancy which led to a potential for maternal death.

(b) Which information would you obtain from the medical records? [9 marks].

Information gathered from medical records includes time of presentation, waiting time before assessment, person carrying out assessment. It will be checked if all entries are timed, clearly documented signed and name printed. Information of presenting complaints such as pain and bleeding and their severity if noted. It will be checked if her last menstrual period is clearly documented as well as previous menstrual history, regularity, use of contraception, previous ectopic pregnancy and PID. Any symptoms of vomiting, feeling faint noted. Her examination findings such as pallor, pulse, BP, abdominal examination, site of pain, speculum and internal examination findings if documented. Investigations carried out are identified such as pregnancy test, full blood count, hCG and pelvic ultrasound. Senior advice obtained or sought will be noted. Nature of treatment given and advice provided such as warning symptoms to report, who to contact identified. If any interpreters were used this is checked. Any telephone numbers and written information provided noted.
Any missed information, examination, investigation, communication identified.

Which additional information would you require for your investigation? [4 marks].

Additional information will include statements from the persons who assessed the patient. Any staffing problems that day, any other emergencies that took priority are checked. If senior consultation was not obtained then reason sought. The set up of the emergency gynaecology clinic with nurse, junior doctors, consultant cover and facilities for ultrasound and laboratory facilities for hCG will be checked. Availability of unit protocol and clearly defined pathway of care if available noted. It will be checked if the patients care was in adherence to protocol.

What are the possible outcomes of your investigation? [5 marks].

The possible outcomes are that care may have been provided according to protocol in which case loopholes in the protocol have to be identified. The care may have deviated from protocol in which case it could be an act of negligence. There may have organisational problems such as a staffing problem, lack of senior cover, lack of facilities for urgent hCG, ultrasound. There may have been a lack of a clear unit guideline and pathway of care. A lack of clear communication may be identified.
Posted by N K.
(a) How would you classify this incident and why? [2 marks].
From the given history I would classify this event as a serious risk category and as an error or near miss with substandard care, resulting in bad outcome with low probability of recurrence – rare or unlikely. The reason is that she was assessed and discharged from the clinic with out appropriate follow up plan, which was an error which resulted in an event of serious consequence – ruptured ectopic, emergency laparoscopy and transfusion of all these blood components. This could have resulted in a fatal incident or still could be fatal.

(b) Which information would you obtain from the medical records? [9 marks].
All the possible written information regarding her consultation at the emergency Gynae clinic needs to be obtained for a detailed risk analysis.
First of we need to identify the medical personnel involved in her care, their level of experience and responsibility and adherence to protocol if any.
From her history it is important to note the date and time and the probable gestation at presentation and associated risk factors for ectopic such as previous PID, endometriosis, tubal surgery and IUCD. Her symptoms at presentation such as abdominal pain- its severity and localization, PV bleeding- amount and co lour and associated symptoms-nausea, vomiting, shoulder tip pain.
Examination findings are important – Observations such as BP, pulse, general examination findings, abdominal examination finding – tenderness, guarding, rebound tenderness, mass or distension. Vaginal examination finding are also important as some signs such as brownish PV discharge with cervical excitation and adnexal tenderness or mass would point towards ectopic pregnancy.
It is necessary to check whether investigations are carried out and results such as beta HCG less than 1000 with empty uterus at trans-vaginal scan may suggest Ectopic location of pregnancy and also low Hb would point towards internal bleeding.
Final impression after diagnosis, proposed plan of action and the reason for discharge will be helpful in risk analysis.

(c) Which additional information would you require for your investigation? [4 marks]
Statements and interview particulars form all the staff involved in her care needs to be obtained and also an opinion of an expert from the records, statements and interviews. It is necessary to verify the investigation results and additional details regarding investigations if not recorded in the notes such as ultrasound reports.
I would also check whether there is any patient complaint or letter is available.


(d) What are the possible outcomes of your investigation? [5 marks].
This is an incident with substandard care with bad outcome. Blame culture should be avoided in all circumstances. Incident should be discussed in a risk management meeting and incident classified. Proposed plan of actions such as development of care path ways or protocols (development or revising), initiation of audits and discussion with personnel responsible by a senior colleague in private if necessary and training need identified.
Posted by Farina A.

a) I would classify it as maternal incident with high frequency and high impact .As ectopic pregnancy is a relatively common clinical condition and if not diagnosed at an earlier stage may lead to catastrophic haemorrhage and even death.

b) From her medical records I would like to know about her presenting complains amenorrhea, regularity of cycles, abdominal pain its severity and location, risk factors for ectopic pregnancy, that is history of previous pelvic surgery, PID, sexual behavior and use of any contraceptives, examination findings, the degree of tenderness and presence of mass in adnexia or cervical exietation are important clinical findings that would have been evaluated at her initial presentation. Involvement of a senior college, proper documentation, investigation facilities available at the emergency gynae clinic and its utilization, adherence to the unit protocol all are important aspects to know. Time interval from arrival and discharge gives an idea of duration of observation. Whether ß HCG levels were done or not and if not what was the reason.

c) I would like to know about the designation, training, level of competence and supervision of the medical staff who assessed her at her first presentation. If senior openion was not taken the reason of not taking the opinion should be enquired. Any problems in communication with the senior staff is important organizational matter to be addressed. Availability of staff and equipment for the transvaginal scan should be ensured. Possible delays in her later presentations should be noted.

d) Possible outcomes could be mitigation or elimination of adverse clinical events like missing an ectopic pregnancy. Continuity of care to the pt, avoid future incidences, proper training and drills, patient satisfaction, avoidance of future litigations. Safeguarding the assets of the organization in terms of its reputation, finance and morale of the staff.
Posted by H P.

(a) I would classify this event as an error. The patient has been assessed in the emergency clinic and may be or may not be diagnosed as having an ectopic pregnancy. She may have been managed as pregnancy of unknown location or complete abortion. A plan must have been put into action which has not gone as intended because patient may have refused admission or maybe a wrong plan was used if diagnosis of ectopic pregnancy was missed.

(b) From the medical records, I would like to know the time of assessment; may be it was duty changeover time and certain findings were not communicated. I will check who saw the patient whether a midwife or SHO or registrar or a locum doctor who may not be familiar with the protocols. I will check what complains she presented with, whether there was any indication of pregnancy, vaginal bleeding, abdominal pain or fainting episodes. I would check if her history was suggestive of having an increased suspicion of ectopic like previous pelvic inflammatory disease (PID), tubal surgery or artificial reproductive techniques.
I would check her clinical findings, if there was any pallor or tachycardia. Whether a per abdomen, speculum and vaginal examination was done and the findings. There could be scars of previous surgeries. The patient may have been clinically stable but there may be signs of localized tenderness on abdominal palpation or cervical excitation. There could be vaginal discharge suggestive or PID or bleeding per vaginum.
I will check what investigations were ordered. If there was a high suspicion of ectopic by history and clinical examination whether a beta-HCG test done and a transvaginal ultrasound arranged and who did the USG
If the tests were ordered, when did the results become available. Was it communicated to the patient or the implication informed. I will check if the patient was made aware and offered admission. If she was offered admission, did the patient decline. I will check if any senior person involved in decision making and communicating to the patient. When the patient went home, I will check whether she was given information about when to immediately report back and if any contact numbers given.
I will check if her symptoms were suggestive of medical or surgical cause like acute appendicitis or cholecystitis, appropriate consultation done or not.

(c) I will take statements from the staff and the patient when she is stable. I will check whether there was any other emergency at the same time which was critical and so attention was diverted or less time devoted to this patient. If not documented, I will check if senior opinion was sought on phone. May be the senior persons were involved with some surgery and not available at that moment of decision making. I would check about the available staff and if they were short staffed or busy with other patient. I would check if there are any protocols in place for management of suspected ectopic and whether they are easily accessible. I would check the quality of ultrasound equipment and whether a skilled person was available at that time. I will check if the laboratory was able to do the beta-HCG on urgent basis.
(d) The investigations will help identify whether the error occurred by active failure or latent failure. If there are inherent problems in the system as under staffing / absence of local protocols or poor quality or absence of ultrasound equipment it is a latent failure. If the staff is not trained regularly or protocols are not updated regularly then also it is a latent failure. If the clinician/ operator failed to diagnose or have suspicion of ectopic pregnancy even after clinical signs or laboratory and ultrasound results then it is active failure. The outcome will depend on the error identified. Staffing problems need to be solved. Equipment and training issues to be addressed and regularized. A local protocol will be drawn and put in accessible place. It may be that the patient did not understand or there was problem of communication; that would need recruitment of interpreters and information leaflets available for the patients to understand and report early. If the senior input was inadequate or they were not involved, they could be more approachable. Summary of report (in anonymity) and changes implemented should be given to all staff members so others can learn. Regular audits should be done to ensure that the protocols are being followed.
Posted by SK K.
a)I would classify this incident as a hazard as it has the potential to cause unintended patient harm, loss or damage. This hazard is an adverse event as it has caused actual harm to the patient. I would further describe this event as a near miss as it has not lead to actual patient loss.

b) It is important to scrutinize the medical records to gain following knowledge of the actual events at consultation .
The date and time at which the patient presented. The cadre of the carer assessing her eg. staff nurse, junior doctor. Was a note made of her presenting symptoms and there severity? Were her menstrual details noted eg last menstrual period and was there a period of amenorrhea. Was it associated with vaginal bleeding ,pain abdomen and syncope. Were any high risk factors for ectopic pregnancy noted in the patient eg: past episodes of PID, previous ectopic , assisted conception, IUCD in situ. Were her vitals recorded at the time of consultation? were they within normal limits? On examination were there signs of acute abdomen? What were the investigation done at that time.Were FBS& beta HCG , urine pregnancy test done ?Was a USS/ TVS undertaken?What was the provisional diagnosis made? Was senior input sought. What was the treatment and options provided to the patient. Was she given appointment for the follow-up & contact numbers in case of emergency.

c) Along with the above information that could be gathered from the medical records, this investigation would require further information that would guide risk control.
It is important to know whether the carer had sought a second opinion from seniors and was it possible to contact the senior as may have been busy in other important issues. At the same time was there any other more serious emergency happening that would have diverted attention. Was the staffing number appropriate on floor.Was this consultation done at odd hours where the carer is likely to have been exhausted. Was there effective bidirectional communication between the patient and the carer. Was it that the patient herself had refused the offered treatment. Were the risks explained to her in that case. Also what were the results of the investigation undertaken then.Was the documentation accurate and signed appropriately.

d)the purpose of undertaking this investigation is to formulate a local action plan aimed at minimized the risk of subsequent similar adverse events by creating safe clinical environment.This investigation could lead to the development of new or revision of new protocols and early access to these. It would also entail teaching & training of staff through meetings, reviews, ,discussions.Encourage accurate & timely documentation. Identify inadequate staffing of the unit & provide solution to it. Also it would lead to identification of the error and its classification as active & latent eg: faulty equipment, delay in acquiring investigations and steps towards minimizing them .No blame culture is important aspect of risk control.

Posted by J P.
a.This is an incident because it has caused harm and significant morbidity to the patient by the requirement of blood transfusions and laparotomy..

b.The reason for consultation in gynaec emergency clinic will be seen from the medical records.The presenting symptoms like abdominal pain ,nausea ,vomiting, vaginal bleeding and fainting attacks suggestive of ectopic pregnancy will be looked in the records.Menstrual history ,any period of preceeding amenorrhea will be noted.History of subfertility,any infertility treatment,history suggestive of PID which will increase the incidence of ectopic pregnancy will be noted.Contraceptive use if recorded will be seen.Any history of previous surgeries including surgery for ectopic pregnancy which will affect management will be noted..The chronological sequence of events including the presence of staff ,and the staff who attended including the grade will be noted.Her vitals as recorded in the records will be noted as this will give the general condition of patient at the time of presentation..Adominal and pelvic examination if done and the findings such as uterine size, adnexal tenderness and pain on cervical exitation suggestive of ectopic pregnancy will be noted.
The provisional diagnosis obtained, any investigation done like serum beta hcG and trans vaginal ultrasound if done will be noted along with the results.If any treatment declined or the patient wish for expectant management if noted will be carefully recorded.
c.Detailed enquiry into the medical personnel who attended the patient and the staf f along with their qualification and level of training.Whether hospital protocol or local guidelines followed will be noted. Pending investigations if any like hcG values and the access to lab will be noted.Any senior personnel involved in the decision will be asked.
d.The outcome will be of not blaming others but seriously looking into what went wrong and classification as incident, optimum care –bad out come or suboptimal care –bad outcome.Future formulation of guidelines adherence to guidelines will be ensured. THE result might have been due to misinterpretation or failure of communication or failure of adherence to proyocols which should be avoided.Filling of incident forms will be encouraged.
Posted by San S.
(a) How would you classify this incident and why? [2 marks].
This would be classified as a major incident as it involved a major event causing an emergency admission which was managed appropriately. It also involved major blood products transfusions.

(b) Which information would you obtain from the medical records? [9 marks].
It is important to obtain date and time of the incident. The details of consultation during the clinic visit prior to the event and medical staffs involved should be noted. Details of consultation including presenting complaints, associated symptoms and clinical examination findings should be looked into. Any investigations undertaken e.g. scans and blood tests during the clinic visit and results should be noted. The working diagnosis and subsequent management plan and follow up and documented advice prior to discharge from the clinic should be noted.

Which additional information would you require for your investigation? [4 marks].
All clinical incidents should be discussed in a dedicated risk management meeting involving risk management manager, consultants, nursing and medical staffs. Any deliberate failure of clinical care should be looked into to prevent recurrences. The management of this patient should be comply with local policies or management guidelines of the condition. Any evidence of latent failures e.g. unavailability of scan service, lack of senior advice or support should be noted.
It is also important to investigate if this event could have been prevented and unnecessary retrospective documentation done if appropriate.

What are the possible outcomes of your investigation? [5 marks].
The outcome may conclude that this is a rare and unfortunate event and that she was managed appropriately and the event may not be prevented.
Investigation may identify clinical or management error and emphasis should be made on compliance to management guidelines or admendments make to guidelines to prevent recurrences of event.
In any case, the patient should be debriefed and provided with explanations in an honest and sympathetic manner. Should she wants to lodge a complaint, she should be advised to contact the appropriate department.
Posted by Farkhanda A.
A
This is classified as missed case. To miss a diagnosis in a young woman of reproductive age about ectopic pregnancy which contributed significant direct maternal deaths in last triennium (13) is a matter of serious concern.
B
Information from medical records:-
Medical records for any investigation have a key role in identify the mistakes when studied them retrospectively.
As a member of investigation team, I will note the time of arrival of the patient to the department and time when she was attended. I will also note what was her presenting complaint s . I will note about her menstrual history and last menstrual date. Her general examination including Blood pressure (BP), Pulse and particularly Urin test for pregnancy confirmation.
I also check who attended her, only nurse or senior house officer or registrar was informed or not. I also note whether any risk factor was mentioned in her history, for example, previous history of ectopic pregnancy, any pelvic infection or pelvic surgery. IS any information of contraception was obtained or not as intra uterine contraceptive device (IUCD) increases the risk of ectopic pregnancy.
C
I will try to check from bed beauro about the bed situation on that day/ night, about the staff situation if any shortage. I will also enquire about the duty hours of attending staff, to check the possibility of over work and tiredness. There is a chance that patient did not give typical history of ectopic pregnancy or presentation was like gastroenteritis. I will also note that if unit protocol to deal suspected ectopic pregnancy was in implication or not.
D
Outcome of this investigation is to analyse about training of staff in such type of emergency conditions.
There must be Implication of agreed unit protocol in such type of cases and involvement of senior staff at least of registrar level.
To fill the incident form, not to blame some one but to correct the mistakes. To do audit about all emergencies which came in and how these were treated and where near missed things happened.

Posted by Drxyz A.
DRXYZ

a) This is \"Near Miss\" as patient in came in emergency and her life saved although morbidity was increased.

b) I would check the date and time of the patient arrival in emergency room. Time of the triage and the time when doctor examined the patient. I will look into the presenting complain of the patient about amenorrhoea, pain and vaginal bleeding. I will see what was the LMP, menstrual history, previous obstetrics history like previous history of ectopic pregnancy, history of contraception like IUCD. I will see the readings of pulse, blood pressure and any tenderness over abdomen and look into the investigations which were requested like beta hcG and transvaginal ultrasound and their results which were documented in ER paper. I will look for the diagnosis made by the attending doctor and if the patient was informed about it and look for the follow up advice given to the patient.
I will look if the patient accepted the advice of the doctor or she left against medical advice.

c) I will investigate from the staff in ER about the condition of the ER and any critical patient present at the time of presentation of this patient for first time. I will see which doctor was present at that time and try to find out the competency of the doctor. I will investigate about the equipment\'s condition and staff operating the instrument whether the staff was adequately trained or not. I will find if any hospital guideline is present for the management of early pregnancy and also look if the guideline is up-to-date according to the international guidelines.I will also look if the doctor and staff in ER followed the guideline. I will also find if any senior on call was informed about the condition of the patient and his advice was taken.

d) It can be negligence on the part of doctor present at that time. It can be the due to the shortage of the staff or the senior person not available at that time. May be this incidence was unavoidable due to that fact that she was stable at first presentation and condition deteriorated suddenly. I can be due to the failure to follow the guidelines of the hospital.
Posted by Atashi S.
(a )This incident can be classified as a case of incidental miss .Various reason may left behind it .May be there was improper diagnosis due to inadequate attention of medical staff or failure to follow medical advice by the patient .

(b) I would like to obtain from the medical record what was her initial presentation . wheather she had any H/O missed period ,symtoms of early pregnancy like nausea and vomiting.Presence of vaginal bleeding ,abdominal pain or unilateral uneasiness on one side of the flank which is continuous or colicky in nature . wheather she had any report of investigation such as urine pregnancy test ,serum beta HCG, ultrasonography .Patient was seen by whom is an another important issue mid wife or nurse or junior doctor or consultant .Attending person whether followed clinic guideline or protocol . Wheather patient was advised for addmission but she refused it that is properly documented in notes or not.

(c)Wheather attending clinic had updated protocol for suspected ectopic pregnancy patient. Wheather there was another acute emergency and consultant was busy .USG report may represent intrauterine pregnancy but there may be a another pregnancy sac in one cornu of bicornuate uterus or USG may suggested sign of complete abortion .

(d)May be due to inadequate attention of medical personnel.may be there was work overload .May be patient failed to follow the advice of addmission .Hospital may have not updated guidline for management of such type of patient .Clinician did not follow the protocol.