Transparency and Disclosure.

Disclosure of medical errors and adverse outcomes is expected by regulatory agencies and society as a whole. Disclosure should occur in a systematic way that ensures honesty and transparency regarding the care that has been provided. It is often appropriate to seek professional help from Clinical Risk Management to assist with disclosure of any serious safety event that resulted in harm. Disclosure of medical errors facilitates efforts to prevent recurrence of safety events.

Medicolegal considerations in breast health: the benefits of collaboration between OB/GYNs and radiologists.

A common endeavor shared by physicians practicing in specialty fields of Radiology and Obstetrics and Gynecology is the comprehensive care and diagnosis of women with breast problems and breast disease. Because each specialty provides its respective clinical expertise in breast health, each also shares a concern, which is the high risk of litigation associated with a missed or delayed diagnosis of breast cancer. This shared concern is well documented for both specialties. Instead, it is argued that physicians are better prepared by engaging in the practice of evidence-based breast care in their respective specialties.

Single-site laparoscopic management of a large adnexal mass.

INTRODUCTION: Single-site laparoscopy is gaining acceptance in many surgical fields including gynecology. The purpose of this report is to demonstrate the technique and outcome for removing a large adnexal mass through a single site. CASE DESCRIPTION: A 41-y-old female was referred to gynecology oncology for increased abdominal girth for 3 mo. An ultrasound confirmed a benign-appearing, 37-cm left adnexal mass. The mass was removed through a single-site laparoscopic incision with the aid of drainage and a morcellator. The operating time was 84 min. The patient was discharged 2 h and 35 min later with full return to normal activity in 5 d. CONCLUSION: Large, benign-appearing adnexal masses can be managed safely with superior cosmetic results using single-site laparoscopy.

Klippel-Trenaunay syndrome complicated by ascites and vaginal lymphatic drainage in adolescence: a case report.

BACKGROUND: Klippel-Trenaunay syndrome is a rare disease characterized by capillary malformationsand soft tissue and bony hypertrophy and atypical varicosities. Management of this syndrome is focused primarily on treatment of the complications that arise from these malformations. Ascites and lymphedema are two of the more common complications in these patients. CASE: A 15-year-old female with Klippel-Trenaunay syndrome presented with chylous ascites, vaginal drainage, and unilateral lower extremity lymphedema. Treatment included dilation, hysteroscopy and curettage, and laparoscopic evacuation of abdomino-pelvic ascites with resolution of symptoms for 32 months. Repeat laparoscopic drainage was successful and remains symptom free after 12 months. CONCLUSION: Vaginal drainage of chylous ascites is a rare complication from Klippel-Trenaunay syndrome and can be successfully managed by techniques to remove abdomino-pelvic ascites.

Patient safety in the ambulatory OB/GYN setting.

The frequency of surgical procedures in the office setting is increasing, and patient safety in this setting now has an expanded focus. Methods and strategies, including Ambulatory Patient Safety Guidelines, results tracking, communication, and risk management principles, will be reviewed in this chapter.

Evaluation and management of abnormal uterine bleeding in premenopausal women.

Up to 14 percent of women experience irregular or excessively heavy menstrual bleeding. This abnormal uterine bleeding generally can be divided into anovulatory and ovulatory patterns. Chronic anovulation can lead to irregular bleeding, prolonged unopposed estrogen stimulation of the endometrium, and increased risk of endometrial cancer. Causes include polycystic ovary syndrome, uncontrolled diabetes mellitus, thyroid dysfunction, hyperprolactinemia, and use of antipsychotics or antiepileptics. Women 35 years or older with recurrent anovulation, women younger than 35 years with risk factors for endometrial cancer, and women with excessive bleeding unresponsive to medical therapy should undergo endometrial biopsy. Treatment with combination oral contraceptives or progestins may regulate menstrual cycles. Histologic findings of hyperplasia without atypia may be treated with cyclic or continuous progestin. Women who have hyperplasia with atypia or adenocarcinoma should be referred to a gynecologist or gynecologic oncologist, respectively. Ovulatory abnormal uterine bleeding, or menorrhagia, may be caused by thyroid dysfunction, coagulation defects (most commonly von Willebrand disease), endometrial polyps, and submucosal fibroids. Transvaginal ultrasonography or saline infusion sonohysterography may be used to evaluate menorrhagia. The levonorgestrel-releasing intrauterine system is an effective treatment for menorrhagia. Oral progesterone for 21 days per month and nonsteroidal anti-inflammatory drugs are also effective. Tranexamic acid is approved by the U.S. Food and Drug Administration for the treatment of ovulatory bleeding, but is expensive. When clear structural causes are identified or medical management is ineffective, polypectomy, fibroidectomy, uterine artery embolization, and endometrial ablation may be considered. Hysterectomy is the most definitive treatment.

Intrauterine contraception in adolescents and young women: a descriptive study of use, side effects, and compliance.

OBJECTIVE: Describe characteristics, compliance, efficacy, and side effect profile of adolescents and young women who use intrauterine contraception (IC). STUDY DESIGN: Retrospective chart review of adolescent and young women who had IC devices placed over a 3-year period. Comparative statistics between devices and population characteristics were performed using the Fisher exact and the t test. RESULTS: Eighty-nine patients were included in the study. The mean age at insertion was 19.5 years (range 16-22 years). Copper was used in 13% of patients; levonorgestrel (LNG) was used in 87%. The mean duration of use was 331.3 days (copper vs LNG; P = .2254). Side effects included infection (9%, but no pelvic inflammatory disease), pain (28%), partner felt strings (9%), and bleeding (32%). Reasons for removal included side effects (25%), desired fertility (5%), expulsion (3%), and pregnancy (2%). There were no pregnancies associated with the LNG IC, and there were fewer removals because of side effects than with the copper IUD (P = .0180). CONCLUSION: IC is a reliable method of contraception in teens and young adults. There were fewer removals because of side effects in the LNG group, although overall other variables are similar between methods.

Practice management guidelines for the diagnosis and management of injury in the pregnant patient: the EAST Practice Management Guidelines Work Group.

Trauma during pregnancy has presented very unique challenges over the centuries. From the first report of Ambrose Pare of a gunshot wound to the uterus in the 1600s to the present, there have existed controversies and inconsistencies in diagnosis, management, prognostics, and outcome. Anxiety is heightened by the addition of another, smaller patient. Trauma affects 7% of all pregnancies and requires admission in 4 of 1000 pregnancies. The incidence increases with advancing gestational age. Just over half of trauma during pregnancy occurs in the third trimester. Motor vehicle crashes comprise 50% of these traumas, and falls and assaults account for 22% each. These data were considered to be underestimates because many injured pregnant patients are not seen at trauma centers. Trauma during pregnancy is the leading cause of nonobstetric death and has an overall 6% to 7% maternal mortality. Fetal mortality has been quoted as high as 61% in major trauma and 80% if maternal shock is present. The anatomy and physiology of pregnancy make diagnosis and treatment difficult.

Expanding the SOAP Note to SOAPS (With S for Safety): A New Era in Real-time Safety Education.

The challenges inherent in medical education are multiple, including recognition of different learning styles among students, incorporation of the Accreditation Council for Graduate Medical Education competencies and outcomes measurement into the curriculum, and compliance with mandated duty hours along with a heightened awareness of patient safety required by our regulatory institutions. With the requirement that safety become an explicit part of the residency curriculum across all specialties, educators are charged with innovative ways of achieving this goal. The following commentary addresses this need and suggests an innovative approach to the traditional daily rounds' SOAP (subjective, objective, assessment, and plan) note to incorporate a second S for safety. The use of a SOAPS note elevates each encounter by integrating quality and error avoidance as a component of care. This method teaches the next generation of physicians the importance of patient safety as an integral part of every doctor-patient interaction.

Transparency, apology and disclosure of adverse outcomes.

Medical errors became a common topic of conversation with the release of the Institute of Medicine's "To Err Is Human" in November of 1999. This release reported that as many as 98,000 people die each year from inpatient medical errors. Putting this into perspective, deaths from medical errors surpassed deaths from breast cancer, motor vehicle accidents, and AIDS. Furthermore, medication errors account for more deaths annually than workplace injuries. This article addresses communication of adverse outcomes to patients (disclosure) through transparency and apology.

Electronic residency application service scores: do they correlate with the rank order list for the match?

OBJECTIVE: To investigate the relationship between ERAS-based preinterview scores, residency program postinterview scores and candidate rank order for the match. STUDY DESIGN: Two hundred sixty-three candidates' preinterview and postinterview scores and rank order were evaluated. The rank order was stratified as 1-4, 5-8, 9-12, > 13 and unranked. Spearman's p statistical analysis was used. RESULTS: There was a moderate relationship, r2 = 0.543, between preinterview and postinterview scores for all applicants. There was a significant inverse correlation between preinterview score and rank order, r2 = -0.763, and for the postinterview and rank order, r2 = -0.768. However, there were no significant relationships between factors significant for the top 4 ranked candidates. CONCLUSION: Preinterview and postinterview scores significantly correlated with each other and with the rank order list except for top-ranked candidates. Other factors may influence the rank order list.

Episiotomy rates in private vs. resident service deliveries: a comparison.

OBJECTIVE: To compare the use of episiotomy by private practitioners vs. resident staff and to determine if number of years in practice influences episiotomy use. STUDY DESIGN: A retrospective chart review of vaginal deliveries at 35 weeks or greater between January 2001 and June 2001. The number of years in practice by each private physician was documented. Independent sample t tests and chi2 tests were used to analyze data. RESULTS: In 995 deliveries, episiotomies were performed in 6% of low-risk resident deliveries vs. 26% of low-risk private deliveries (p<0.001). Physicians in practice > or = 15 years performed episiotomies in 32% of low-risk births. Physicians in practice <15 years performed episiotomies in 22% of low-risk births (p = 0.027). CONCLUSION: Deliveries performed by private practitioners are associated with a higher rate of episiotomy than those by resident staff. The number of episiotomies appears to increase by number of years in practice.

How do medical student self-assessments compare with their final clerkship grades?

The purpose of this study was to determine how a medical student's self-assessment at the completion of the third-year Ob/gyn clerkship compares with the institution's final grades at Lehigh Valley Hospital. From November 2002 to November 2003 at completion of each six-week Ob/gyn clerkship rotation, 47 medical students assessed themselves on the following parameters: fund of knowledge, personal attitude, clinical problem-solving skills, written/verbal skills, and technical skills. Additionally, they were asked to predict their performance on the NBME Shelf Exam. Their assessments were then compared with their final clerkship grades in each of the above parameters. Chi-squared and Kendall-tau tests were used to analyse the data for degree of agreement and association, respectively. There was a statistically significant weak to moderate, positive correlation between students' self-assessment and final clerkship grade for written/verbal skills (p = 0.002, r = 0.390). A statistically significant agreement between raters was also revealed for written/verbal skills (p = 0.003). Weak, non-statistically significant, positive relationships were revealed for fund of knowledge, clinical problem-solving and technical skills. A weak, negative, non-significant relationship was revealed for personal attitudes, and there was no statistically significant relationship between students' prediction of NBME score and categorized true score (p = 0.717, r = 0.49). At the end of their Ob/gyn clerkship, third-year medical students are better at assessing their technical and written/verbal skills than their global fund of knowledge and personal attitudes. These results may suggest that students are not aware of their own personal attitudes and communication skills and how they can affect their effectiveness as a physician.