O&G Cases · Professional practice — clinical governance, quality and patient safety
Leading a morbidity and mortality review after a hypoxic event — governance and leadership station
Governance and leadership station on chairing a morbidity and mortality review after an intrapartum hypoxic event. Exercises holding the system lens over the person lens, the London Protocol and fishbone, just culture, named action planning with owners and timeframes, the audit cycle with re-audit, second-victim support, and the open-disclosure commitment to the family. Includes assessor key and marking domains.
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Target exams
Station brief
Format. Governance and leadership station, approximately 12 minutes. You are the consultant chairing the review. The assessor plays the night registrar and feeds contributions from the other team members. The assessor will run the clock and observe how you lead the discussion, hold the culture, and convert the case into owned actions. [1]
Candidate instruction. Lead the review. Demonstrate the system lens, a just culture, a structured analysis of contributing factors, named actions with owners and timeframes, and the loop that closes back to the family and to a re-audit. [2][6]
References6ShowHide
- [1]Scally G, Donaldson LJ The NHS's 50 anniversary. Clinical governance and the drive for quality improvement in the new NHS in England BMJ, 1998.PMID 9651278
- [2]Reason J Human error: models and management BMJ, 2000.PMID 10720363
- [3]Braithwaite J, Travaglia JF An overview of clinical governance policies, practices and initiatives Aust Health Rev, 2008.PMID 18241145
- [4]Coughlan B, Powell D, Higgins MF The Second Victim: a Review Eur J Obstet Gynecol Reprod Biol, 2017.PMID 28526169
- [5]Australian Commission on Safety and Quality in Health Care Australian Open Disclosure Framework ACSQHC, 2013.Source
- [6]Australian Commission on Safety and Quality in Health Care National Model Clinical Governance Framework ACSQHC, 2017.Source