Rapid Root Cause Analysis: Improving OBGYN Resident Exposure to Quality Improvement and Patient Safety Curricula.

Introduction Each year, millions of patients in the United States experience harm as a result of the healthcare they receive. One mechanism used by health systems to learn how and why errors occur is root cause analysis (RCA). RCA teams develop action plans to create and implement systemic changes in healthcare delivery in order to prevent future harm. The American Council on Graduate Medical Education (ACGME) recognizes the importance of analyzing adverse events, and it requires that all residents participate in real or simulated patient safety activities, such as RCAs. Often, institutional RCAs necessitate the assimilation of participants on short notice and demand considerable time investment, limiting the feasible participation of graduate medical education (GME) trainees. This presents a gap between ACGME expectations and the reality of resident involvement in patient safety activities. We present the first iteration of a quality improvement project encompassing a three-hour resident physician training course with simulated RCA-experiential learning. The purpose of this project was to produce a condensed, educational RCA experience that adequately trains all GME learners to serve as informed healthcare safety advocates while also satisfying ACGME requirements. Methods The course ("rapid RCA") was conducted during protected weekly academic training. All residents of the San Antonio Uniformed Services Health Education Consortium (SAUSHEC) Obstetrics and Gynecology (OBGYN) residency program who had not previously participated in a real or simulated RCA were required to take the "rapid RCA." Pre- and post-course surveys were completed anonymously to assess baseline knowledge, new knowledge gained from the course, and attitudes toward the course and its importance to resident training. Results Fourteen OBGYN residents attended the "rapid RCA," indicating that 64% (14 out of 22) of the program had no previous experience or opportunity to participate in a real or simulated RCA. Participation in the course demonstrated a significant gain of new knowledge with an increase from 0/14 to 10/14 (71%) residents correctly answering all pre- and post-course questions, respectively (p < 0.001). Additionally, on a Likert scale from 1 to 5, with 5 indicating "expert level," residents indicated they felt more comfortable on patient safety topics after taking the course (mean pre-course score 1.85 to post-course score 3.64, p < 0.001). All participants indicated they would prefer to take the "rapid RCA" as opposed to the only available local alternative option for a simulated RCA, currently offered as a full-day intensive course. Conclusion A meaningful increase in patient safety knowledge and attitudes toward topics covered in an RCA was demonstrated through the implementation of a "rapid RCA" in OBGYN residents. We plan to incorporate this into our annual curriculum to satisfy ACMGE requirements. This format could be adapted for other specialties as applicable.

Incidental myomectomy at time of vaginal delivery contributing to postpartum hemorrhage: A case report and review of the literature.

BACKGROUND: Uterine leiomyoma are implicated in certain adverse pregnancy related outcomes such as postpartum hemorrhage. Large submucosal leiomyoma defined as greater than 5 cm, may have higher complication rates; however, high quality data is limited. CASE: A 44-year-old gravida 4 with history of two full-term vaginal deliveries presented at 40 and 2/7 weeks of gestation with premature rupture of membranes and delivered vaginally a viable female infant complicated by a postpartum hemorrhage due to uterine atony. During a manual uterine sweep for suspected retained products of conception, a submucosal leiomyoma was incidentally extracted. Uterine hemorrhage immediately ensued, requiring vasopressors, blood transfusion, and intensive care unit admission. Hemostasis was ultimately achieved with placement of a Bakri balloon. CONCLUSION: This case reaffirms the association of large (greater than five centimeters) submucosal leiomyoma with severe postpartum hemorrhage. Caution should be taken with patients who have leiomyoma with these characteristics. The use of balloon tamponade in such situations may aid in hemostasis and avoidance of postpartum hysterectomy.

Speed Mentoring: An Effective & Efficient Path to Development of Mentor Relationships in a Military Obstetrics & Gynecology Residency.

INTRODUCTION: With a deficit of effective military residency mentorships, a paucity of research on successful mentorship programs, and growing reports on innovative mentoring programs, we developed a "Speed Mentoring" event for the National Capital Consortium OBGYN Residency. MATERIALS AND METHODS: The development, implementation, and follow-up responses through participant surveys were designed as an institutional review board (IRB)-approved evidence-based quality improvement project at our institution. Our event coordinated mentorship opportunities between residents and faculty from a wide range of specialties, leadership roles, and research experiences. Residents were matched with faculty that aligned with self-identified goals. Surveys were distributed prior to the event and at follow-up intervals to demonstrate the lasting impact and areas for improvement. RESULTS: Prior to our first event, every resident reported by survey that they desired more mentorship opportunities. However, only 55% could identify a specific mentor, citing limited time and difficulty establishing a relationship. Immediately following the event, 90% of residents scheduled a follow-up with at least one mentor. Forty-seven percent of residents reported inspiration to initiate a new research project. Meanwhile, faculty felt valued and gained satisfaction by "giving back" to their profession. After 1 month, half of the residents and faculty had already conducted at least one meeting. At 3 months, 76% of meetings centered on research and 23% on quality improvement projects. Fifty-seven percent of participants reported future scheduled meetings. At 6 months, 75% of residents reported meaningful mentorship relationships. CONCLUSIONS: After demonstrating a need for improved mentorship opportunities, we implemented an efficient way to foster mentorship while expanding resident involvement in research, QI projects, and fellowship applications. This "Speed Mentorship" program can be easily adapted to all residency programs.

Mayer-Rokitansky-Kuster-Hauser Syndrome: A Unique Case Presentation.

Background: Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is a congenital condition characterized by aplasia of the vagina with or without concurrent uterine and/or cervical aplasia. Type II (MURCS) is a rare form involving MUllerian agenesis, Renal agenesis, and Cervicothoracic Somite anomalies. Case: A 17-yr-old virginal female presented for evaluation of primary amenorrhea and pelvic pain. Her medical history was significant for a bicuspid aortic valve and right radial dysplasia. She demonstrated normal secondary sexual development and a normal karyotype. Pelvic magnetic resonance imaging revealed an aplastic vaginal, no identifiable cervix or uterus, and normal ovaries. A laparoscopy was performed for the evaluation of pain and findings were significant for bilateral uterine horn and fallopian tube remnants noted along the pelvic sidewalls. This patient evaluation suggests a unique presentation of MURCS association. Conclusion: To our knowledge, this is the first case of MRKH presenting with a bicuspid aortic valve and radial dysplasia. A review of the literature reveals no other cases of MRKH with these unique anomalies.

Alterations in antibody subclass immune reactivity to trophoblast-derived fetal fibronectin and α2-macroglobulin in women with recurrent pregnancy loss.

PROBLEM: Increasing evidence supports the involvement of complex antibody-mediated immunologic events at the decidua-trophoblast interface. Our objective is to define the humoral immune responses of pregnant women with a history of recurrent pregnancy loss (RPL) compared with gestation-age-matched and non-pregnant controls in terms of trophoblast-derived antigenic targets and IgG subclasses. METHOD OF STUDY: Immunoprecipitation and Western immunoblotting were performed to characterize IgG subclass reactivity to Sw.71 trophoblast-derived fetal fibronectin and alpha-2-macroglobulin, using serum obtained from first-trimester pregnant RPL subjects, gestation-age-matched controls, and non-pregnant controls. RESULTS: Using a generalized linear model, sera from women with a history of RPL exhibited increased IgG(3) immunoreactivity to trophoblast-derived fetal fibronectin and alpha-2-macroglobulin compared with controls (P < 0.001 and P < 0.001, respectively). CONCLUSION: IgG(3) reactivity in women with RPL may play a significant role in aberrant immune-regulatory mechanisms in early pregnancy. Further investigations into the role of autoantibodies against trophoblast-derived proteins in implantation and pregnancy are warranted.

Current methods of tubal patency assessment.

OBJECTIVE: To evaluate the scientific literature on current methods of uterine cavity and tubal patency assessment. DESIGN: Review of literature and appraisal of relevant articles using MEDLINE, OVID, EMBASE, and Cochrane on-line databases. RESULT(S): Current pelvic imaging subfertility investigations are compared with the gold standard laparoscopy. The technical aspects, associated risks, potential advantages, and weighted utility of each screening study are discussed. A comprehensive analysis of the clinical evidence regarding the safety, tolerance, and accuracy of hysterosalpingo-contrast sonography compared with alternative screening studies and/or laparoscopy is reviewed. CONCLUSION(S): Increasing evidence supports the more recently described hysterosalpingo-contrast sonography procedure as an acceptable screening study for the subfertile patient with the potential advantage that it is a comprehensive evaluation, methodologically simple, cost effective, and time efficient.