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Audit of operative consenting Risk Management Meeting RCOG, May 2008

Audit of operative consenting Risk Management Meeting RCOG, May 2008. Dr Dana Touqmatchi Dr James D M Nicopoullos. RCOG, Clinical Governance Advice, 2003. Audit Cycle. Selection of a topic Identification of an appropriate standard Data collection to assess performance

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Audit of operative consenting Risk Management Meeting RCOG, May 2008

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  1. Audit of operative consentingRisk Management MeetingRCOG, May 2008 Dr Dana Touqmatchi Dr James D M Nicopoullos

  2. RCOG, Clinical Governance Advice, 2003

  3. Audit Cycle • Selection of a topic • Identification of an appropriate standard • Data collection to assess performance • Implementation of change to improve care • Data collection to determine improvement in care RCOG, Clinical Governance Advice, 2003

  4. Audit Cycle • Selection of a topic • Identification of an appropriate standard • Data collection to assess performance • Implementation of change to improve care • Data collection to determine improvement in care RCOG, Clinical Governance Advice, 2003

  5. Audit Topic • Quality of Surgical Consent • Focused area • High volume area • Associated with potential for high morbidity • Good evidence to inform practice

  6. Importance of consent • CNST (April 1995 – March 2007) • 40,165 total claims • 8,532 O&G claims • 21% of all claims • 2nd highest specialty • O&G claims incur highest cost • £2,475 million • More than next five most costly combined (£2423million) • NHSLA Factsheet 3, 2007

  7. Importance of consent • “Obtaining Valid Consent” (RCOG, Clinical Governance Advice, 2004) • “Good practice in consent: achieving the NHS Plan commitment to patient-centred consent practice” (Department of Health, 2003) • “Seeking patients' consent: The ethical considerations” (General Medical Council, 1998) • “Consent Toolkit” (British Medical Association, 2003)

  8. Audit Cycle • Selection of a topic • Identification of an appropriate standard • Data collection to assess performance • Implementation of change to improve care • Data collection to determine improvement in care RCOG, Clinical Governance Advice, 2003

  9. Audit Standard “Aim is to ensure that all patients are given consistent and adequate information for consent”

  10. Audit Standard • Consent Advice 1 - Diagnostic Hysteroscopy • Consent Advice 2 - Diagnostic Laparoscopy • Consent Advice 4 - TAH • Consent Advice 5 - Vaginal Repair / VH (October 2004, RCOG) • Consent Advice 7 – LSCS (May 2006, RCOG)

  11. Audit Standard • Common Themes • Follow structure of DOH Consent Form • Intended Benefit • “Recommended that clinicians make every effort to separate serious from frequently occurring risks” • Documents “Serious” risks • Documents “Frequent” risks

  12. Audit Standard • Common Themes • “Women who are obese, have had previous surgery or who have pre-existing medical conditions must understand that the quoted risks for serious or frequent complications will be increased” • Additional Procedures • Information Leaflet given in clinic • Awareness of type of anaesthesia

  13. Audit Cycle • Selection of a topic • Identification of an appropriate standard • Data collection to assess performance • Implementation of change to improve care • Data collection to determine improvement in care RCOG, Clinical Governance Advice, 2003

  14. Data Collection • 3 month audit period (Sept-Nov 07) • First 20 notes for Consents 1,2,4,5 • First 40 notes for Consent 7 (LSCS) • Watford General site only • Data collected by 1 clinician (DT) • Data input directly onto Excel proforma based on RCOG standards

  15. Consent Advice 1 – Diagnostic Hysteroscopy

  16. Consent Advice 1 – Diagnostic Hysteroscopy • 1/20 documented information leaflet given • 6 consent forms failed to mention any side –effects / extra procedures • 5 consultant • 1 SHO

  17. Consent Advice 2 – Diagnostic Laparoscopy

  18. Consent Advice 2 – Diagnostic Laparoscopy • 1/20 documented information leaflet given • 4 consultant consents with 0/4 mentioning risk of perforation or requiring open intervention/repair • Need to mention risk of death??

  19. Consent Advice 4 – TAH (Benign)

  20. Consent Advice 4 – TAH • Information leaflet given – 10% (2/20) • 2 consent forms had no hospital numbers • 14 failures to mention either • bladder damage • bowel damage • VTE • 12 of 14 consultant consents • 1 consent form mentioned only bladder damage

  21. Consent Advice 5 – Vaginal Repair/VH

  22. Consent Advice 5 - Vaginal Repair / VH • Information leaflet given – 5% (1/20) • 5 failures to mention Bladder damage • 3 Consultant / 2 SpR • 4 failures to mention Bowel damage • 3 Consultant / 1 SpR • Dyspareunia/QOL mentioned in 2 forms • Both by same consultant • GMC implications • Recurrence mentioned in 5 forms • 4 completed by same SpR • No consultant mention of any additional procedures

  23. Consent Advice 7 – LSCS

  24. Consent Advice 7 - LSCS • 1 consent form not completed at all – ? Grade 1 • Consent outcome biased by type of LSCS • Taking Elective alone • No consents mentioned • Effect on repeat LSCS • Risk of IUD • Risk of Placentation problems • 7 failures to mention visceral damage/infection/VTE

  25. Consent – By risk category

  26. Consent – Who is consenting?

  27. Consent – By Grade overall

  28. Audit Cycle • Selection of a topic • Identification of an appropriate standard • Data collection to assess performance • Implementation of change to improve care • Data collection to determine improvement in care RCOG, Clinical Governance Advice, 2003

  29. Implementation of change • Consultant agreement on standards • Options considered to improve documentation: • Improved awareness of RCOG guidelines • Dedicated teaching session • Dedicated induction session • Pre-printed Consent Forms • Time • Cost • Consultants to “delegate” junior staff to consent routine cases

  30. Implementation of change • Increased accessibility of Guidelines • Elizabeth Ward • Day Surgery Unit – all sites • Gynae Emergency Treatment Room • Pre-clerking clinics – Antenatal / Gynae • GOPD

  31. Elective LSCS Proforma • Checklist for use at: • Counselling at LSCS clinic • LSCS consent clinic • Particularly for VBAC/Maternal choice counselling

  32. Audit Cycle • Selection of a topic • Identification of an appropriate standard • Data collection to assess performance • Implementation of change to improve care • Data collection to determine improvement in care RCOG, Clinical Governance Advice, 2003

  33. The way forward Implementation of Recommendations ??Re-education?? Printed Guidelines in accessible/visible locations Re – audit after suitable time period

  34. Conclusion • Audit of 120 case-note consent forms • Against recognised RCOG guidelines as standard • Significant deficiencies identified • Action plan suggested • Re-audit

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