1. Prof. M.C.Bansal
MBBS., MS., FICOG., MICOG.
Founder Principal & Controller,
Jhalawar Medical College & Hospital Jjalawar.
MGMC & Hospital , sitapura ., Jaipur

2.  Harvard Medical Practice Study(1991) : To err is human (1999)
changed the world of risk management in medicine forever.
 In their summary , it turned out that preventable errors in
medical practice were more frequent, caused as much patient
harm and cost a tremendous amount of money to the healthcare
system.
 Prominent problems in modern practice today include wrong side
surgery, retained foreign body, surgical site infection, burns
during surgery, mismatched blood transfusion and medication
errors.
 This is specially true for obstetrics & gynaecology where
litigation is the highest all over the world.
 If you know the problem ,the
solution is quite clear.

3.  Human error is involved in 70% of all accidents
including healthcare system.
 Robert Helmeich a Psychologist and pioneer in error
Errors result from
management wrote 
physiological and psychological
limitations of human beings.
 Causes of errors include fatigue, work
load,fear, cognitive overload, poor inter
personal communication imperfect information
processing and flawed decision making.

4.  Effective error management is based on
proper understanding of the nature and
extent of human error.
 Error /negligence ---SHAME AND BLAME---
The doctor at the end of chain of events is
found guilty for committing the error and for
the adverse clinical outcome which lead to
DEFAME.

5.  James reason‟s Swiss cheese theory-No accident
happens with out a series of mishaps illustrated
by holes in slices of Swiss cheese , the slices
represent the different stages in the process ,
while holes in the cheese represent active and
passive errors with in each stage.
 Main reasons for errors are inherent in the
system, rather than being caused by an individual
person in the system.
 Don Bewrick CEO of institute of health care
improvement----EVERY SYSTEM IS PERFECTLY
DESIGNED TO ACHIEVE EXACTLY THE RESULTS IT
GETS

6.  James Resason describes “Just Culture” –as
an atmosphere of trust in which people are
encouraged ( even awarded ) for providing
essential safety – related information , but in
which they are also clear about where the line
must be drawn between acceptable and
unacceptable behavior .
 In all dangerous clinical situations ,where
errors are triggered by environmental and
personal factors – lead to errors and even
harm to patient.

7.  In summary ,in order to reduce clinical risks
successfully, it is necessary to solve the problems
that arise because of the limitations of human
performance , induced and enforced by
environmental , personal or team factors .
 In clinical practice –necessary skill, knowledge
and to follow standardized routine procedure are
mandatory.
 With out specific risk management tools ,such as
RM-SOPs and NOTCHES , all the efforts will have
a very little effect in reducing clinical risk at front
line.

8.  1 Situation awareness developing and
maintaining a dynamic awareness of the situation
in theatre, based on assembling data from the
environment (patient, team, time, displays,
equipments), understanding what they mean,
analytical thinking ahead what may happen next
 Gathering information
 Understanding information
 Projecting and
 Anticipating future state

9. 2 .Decision making
skills for diagnosing the situation and
reaching a judgment in order to choose an
appropriate course of action.
Considering various options
Selecting and communicating
options
Implementing and reviewing
decisions.

10. 3.Communication and team work
Skills for working in a team context to
ensure that the team has an acceptable
shared picture of the situation and can
complete the task effectively and timely.
Exchanging information
Establishing a shared
understanding
Co-coordinating team activities

11. 4.Leadership
Leading the team and providing direction,
demonstrating high standards of clinical practice
and care and being considerate about the needs
of individual team members.
Setting and maintaining
standard
Supporting others
Coping with pressure
BASED ON THE
CLASSIFICATIONOF FLIN ET AL.

12.  Acceptance and correct use of RM-SOPs is
essential for effective risk reduction.
 Table 1-tools of risk management
- Checklist
- Communication strategies
(closed –loop, read back, repeat
back )
- Briefings
- Debriefing

13.  Table 2
- Correct use of check list
- Skills of safe communication
strategies
- Use of briefings
- Use of debriefings

14. Benefits
It is easily demonstrated that humans
have very limited ability to remember more than
5 items at once. Activity like going to
supermarket one prepares the list of glossary to
be purchased.
Well designed and complete
checklist prevents us from forgetting the things.
checklist additionally free our mind for other
more complex and important problems that can
not be managed success fully by such simple
techniques.

15. Clinical example 
Management of Eclampsia.
- Well designed and complete checklist of all
the steps to be taken in a sequence will help
in minimizing the errors and decreasing the
risk.
- This in turn will help us in getting good
fetal and maternal outcome.

16.  Checklist are only effective if they are used
every time you perform any specific
procedure, even you are fully trained and
experienced .
 When you are tired, overworked or when
there is some other operational problem ,you
would like to avoid problems than only you
will be convinced of the value of a checklist
and trained in its use.

17. Benefits
There are many situations when be
all desire clear and complete communication
to other team members to ensure that right
information is correctly transmitted.
Benefit is clear –there will be no
confusion/ misunderstandings.
Clinical example----Ordering high risk
medications such as cytotoxic chemotherapy
or anticoagulant.

18.  Think about asking telephone number/address.
What we do ?
 The technique is---
1. Say it .
2. Ask the recipient to repeat it
or write it down and read it.
3. Confirm it .
This is west way to know whether the information has
been
understood correctly. Technique is valuable when
ordering
high risk medicines that sound alike, such as
dioval/diovan,
lasix/luvox,texol/taxotere and many others.

19.  Benefits
Briefing is a structured type of
interaction used to achieve clear and effective
communication in a timely manner .Each of
us feel better as a team member if be know
the plan of job to be done by the team.
It is evident that sports team or
orchestras will perform best if all team
members are aware of the plan well before
the final show is to be performed.

20.  To make briefing successful. instructions
must be clear, short and precise .Ideally there
should also be the opportunity for questions
from team members.
 Briefing should take place as a minimum: (1)
start of day,(2)Prior to procedure,(3)as the
situation changes,(4) during hand
offs(e.g.Tea break, shift change,etc)

21.  Before starting the operation confirm
the following important information's-
--
1.Indication of procedure.
2.recapitulate about steps of
procedure.
3.Correct site and side.
4.Possible drug allergies .
5.previos drug reaction.
6.Special instruments/ suture
material will
be needed .

22.  Benefit
Whenever the team has completed the
procedure , there should be a short session of all
team members to review the mission.
This provides greatest chance for
individual s and team to learn from present
difficulties and problems faced during present
operation and thereby improve their future
strategies.
The entire team meats and reviews the
management which has taken place. Three
questions are to be answered (1)What went right
(2) What did not go so well,(3)What we should do
next time?

23.  Technical skills are essential but are often
inadequate to get everything right- for
example a perfect operation done on wrong
limb is perfect so far skilled technique of
operation is concerned, this puts the team in
problem.
 This type of risk may be minimized by using
so called “Non Technical Skills”
 NOTECHS------

24.  A significant problem in dealing with
NOTECHS is that they could not be measured
objectively.
 The NOTSS system developed by Prof. Rhona
Flin and her team allows explicit rating and
feedback to be given in relation to non
technical skills.
 It is ,in effect ,a behavioral marker system
and may be used to structure training . It is
also useful in evaluation of non technical
skills in surgery a similar fashion to current
practice in anesthesia, civil aviation and
nuclear power industry.

25.  How RM_SOPs and NOTECHS can be used
together?
 Certain catastrophes in medicine (e.g. wrong
side surgery, Transfusion errors, left over
packing in abdomen) Happen over and over again
is a clear indicator that we have yet not solved
the problem of risk reduction at the front line.
 Paul Watzlawick: „ If you have not found a
solution for your problem ,It is not the
problem, but the solution you have to work on.
 So what we can do to become as successful in
risk and error reduction as high risk industries
have been for many years?

26. 1. We have to accept that we, as humans, are
limited in error free performance by the so
called “human performance limitations”
2. To achieve this goal ,it is necessary to have
interactive classroom teaching involving all
members of healthcare team (nurses,
doctors, midwives other assistants etc.)Did
active teaching without interactivity will not
achieve the target.
3. At the end trainees should be convinced
that one needs SOPs of risk management to
overcome The „human error‟.

27.  We have learn and reinforce the RM_SOPs that
protect us from committing errors and help us in
critical situation to achieve the best possible
outcome ,whether working alone or in teams
 Even if you are convinced of the value of RM-SOPs
and have been trained to perform them correctly,
it is likely that you will fail in life ,if you ignore the
use of NOTECHS.
 Lack of NOTECHS results in team and
communication problems impairing good
outcome.
 One of the major problem in this context is the
Heirachial structure of medical practice.
3.Subsequently after education and training in RM-
SOPs ,one needs to be trained in NOTECHS To
perform effective risk reduction.

28. 1.The main reason for inadequate risk
management in healthcare is the fact that the
most care givers ignore effective strategies and
need for appropriate systemic implementation of
risk management at the front line
2.Hierachial working practices ., the shame and
blame culture has to be eradicated in favor of a
“just culture”.
3.The effective risk reduction is only possible when
problems surrounding ethos, human
performance limitations and non technical skills
are taken in account and treated seriously.
4.OB-GY Specialists are frequently exposed to
risky situations ,should learn and practice these
effective strategies of RM-SOPs and NOTECHS.