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Failure modes and effects analysis to assess COVID-19 protocols in the management of obstetric emergencies
  1. Sam Curtis,
  2. Rebecca Flower,
  3. Lola Emanuel-Kole,
  4. Premala Nadarajah
  1. Department of Anaesthesia, Royal Free Hospital, London, UK
  1. Correspondence to Dr Sam Curtis, Anaesthesia, Royal Free Hospital, London NW3 2QG, UK; sam.curtis1{at}


The Royal Free Hospital is one of four High Consequence Infectious Disease centres in England and as of the end of May 2020, seven women were confirmed COVID-19 peri-delivery. We developed a standard operating procedure (SOP) for suspected and confirmed COVID-19 women undergoing operative delivery. This was revised in response to our ongoing clinical experience and changes in guidance from medical and public health organisations. Following 10 weeks of clinical practice, we formally tested the SOP using point-of-care simulation to enable optimisation for a potential second surge. Our high-fidelity simulation of a COVID-19-positive parturient requiring an emergency caesarean was facilitated by the simulation team in our obstetric unit. It was designed to test the performance and safety of our SOP as well as staff performance. We used the Failure Modes and Effect Analysis tool (a systematic, prospective method of process mapping) to identify how a complex task might fail and assess the relative impact of different failures. The decision-to-delivery was 17 minutes, which we considered to be successful. However, a number of operational deficiencies were identified. The main failures related to lack of situational awareness, ill-fitting personal protective equipment and difficulties communicating between theatre and the neonatal teams located outside, posing serious potential risks to safe neonatal care. Subsequently, we have modified our SOP to include a communication check, implemented communication training for the neonatal team and organised further simulation training for theatre staff unfamiliar with COVID-19 considerations.

  • simulation
  • anaesthesia
  • patient safety
  • obstetrics

Data availability statement

Data are available on reasonable request. Results from the simulation study and trust SOP are available from the supervising author.

This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

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The COVID-19 pandemic places a huge burden on healthcare delivery and novel risks to patients and staff.1 Its evolution required the rapid formation of institutional pathways based on expert opinion and emerging scientific evidence.2 3 In situ simulation is a technique that can inform the development and testing of such pathways in a safe manner, especially when facing novel clinical challenges.2 Simulation-based training has been identified as an important training modality to improve healthcare delivery in high-pressure situations.3–5 Whilst it demands the coordination of many healthcare providers and resources,it can significantly improve patient care and safety.6 7 Its potential uses in the COVID-19 pandemic include:

  • Supporting organisational response to the current crisis

  • Evaluating new or temporary care settings;

  • Supporting and training staff to practise new skills

  • Modifying policies and procedures

  • Facilitating individual and organisational learning

The Royal Free Hospital is one of four High Consequence Infectious Disease centres in England.8 Our obstetric department performs approximately 3000 deliveries a year. As of the end of May 2020, seven women were confirmed with COVID-19 peri-delivery. Here, we share our experience in the use of in situ simulation to ensure safe provision of obstetric services during the COVID-19 pandemic.

A standard operating procedure (SOP) for suspected and confirmed COVID-19 women undergoing operative delivery at our hospital was formulated for the obstetric multidisciplinary team. A COVID-19 simulation team was formed, consisting of consultant anaesthetists and fellows in simulation. The team was assembled specifically for the COVID-19 surge and ran a series of dedicated simulations on emergency intubation and personal protective equipment for all obstetric staff.2 In addition, they undertook a point-of-care simulation for the transfer of an obstetric patient with COVID-19 from isolation to theatre using the failure modes and effects analysis (FMEA) tool to guide safety.9

The SOP was modified in response to our clinical experience and changes in guidance from Public Health England, the Obstetric Anaesthetists Association and the Royal College of Obstetrics and Gynaecology.10–12 A key development at the time was the decision to treat all delivering women as suspected COVID-19 due to lack of available testing.11 Training was then required to educate labour ward staff on the appropriate use of personal protective equipment depending on the stage of labour and type of delivery.

The reorganisation of obstetric theatres into clean and dirty areas presented a number of issues, which included restricting access to theatre and reallocating equipment and drugs away from contaminated areas. The combination of donning personal protective equipment and these modifications posed risks to delays in delivery time. In order to increase efficiency and safety, we created standardised colour-coded drug containers for general and regional anaesthesia and standardised intubation crates containing all the equipment required to intubate patients with COVID-19. A runner was allocated outside theatre to provide any extra equipment or drugs neededand communication was conducted using two-way radios.

Following 10 weeks of clinical experience, we sought to formally reassess our SOP and departmental systems to optimise ongoing care for patients with confirmed COVID-19.


Due to the lack of patient involvement, our research and development department stated that ethical approval was not required. Written, informed consent was obtained from all participants.

The high-fidelity point-of-care simulation was developed and facilitated by the simulation team and carried out on 21 May 2020 in our obstetric unit. Participants involved in the simulation were briefed and consented to participate on the morning of the exercise. The scenario was designed to test the safety of our COVID-19 SOP, institutional processes and participants’ behaviour, teamwork and communication. We used the FMEA tool, a systematic, prospective method of process-mapping to identify how a complex task might failand to assess the relative impact of different failures.13 14 The simulation team consisted of anaesthetic consultants with specialist interest in simulation and simulation fellows. They prospectively identified failure modes and hazards following analysis of the SOP. They also highlighted any failures in systems processes, communication and teamwork.

To test the full scope of the SOP,the following scenario was devised. A confirmed COVID-19 labouring woman required emergency caesarean section under general anaesthesia due to severe fetal distress. Following delivery, the neonate would require 5 min of resuscitation before the scenario was terminated following an improvement in the Apgar score. The objective was timely and safe delivery of the neonate while protecting staff from risks of exposure to COVID-19.

To best represent a real-life scenario, the simulation was conducted during a normal working hours, using anaesthetists, obstetricians and theatre staff rostered to work on the obstetric unit that day. A high-fidelity Laerdal 3G SimMan (Laerdal Medical, Orpington, UK) and ‘neonatal sim model’ were used to represent mother and baby. Participants were instructed to call on any additional clinical staff as appropriate.

The participants were briefed that a labouring 36-week patient with confirmed COVID-19 is on labour ward in an isolation room. Shortly following the briefing, signs of severe fetal distress developed with prolonged bradycardia on the CTG. Participants were then assessed on decision-to-delivery time, conduct of general anaesthesia and surgery and management of neonatal resuscitation.

Failure modes were recorded separately by two members of the simulation team and a structured debrief was performed on all participants.


The scenario was concluded at 25 minutes and the time interval for decision-to-delivery was 17 minutes. A number of operational deficiencies were identified. The active failures and latent threats recorded and subsequent organisational responses are summarised in table 1.

Table 1

Summary of the active failures and latent threats identified, with the subsequent organisational response.

Feedback from the participants was broadly positive in terms of experience and confidence following the simulation.Participants did, however, report difficulties with non-verbal communication due to the use of personal protective equipment and heightened anxiety due to additional COVID-19 considerations.


Our simulation was broadly positive in affirming the progress we have made in the last 10 weeks in terms of staff training and implementation of our protocols. The total time from decision-to delivery of the fetus was 17 minutes, which we considered excellent when following full personal protective equipment guidance and protocol. Furthermore, participants were positive regarding the experience and reported less anxiety when faced with these cases than 8 weeks previously.

Based on findings from the simulation, the following changes have been implemented at our trust:

  • Training for neonatal team on use of two-way radio and procedure for communicating in personal protective equipment

  • Further simulation training for operating department practitioners (ODPs) and theatre staff unfamiliar with COVID-19 considerations

  • Acquisition of protective gowns that fit all members of staff

  • Modification of COVID-19 intubation checklist to include sodium citrate and oxford Head Elevating Laryngoscopy Pillow (HELP) pillow

  • Additional step at ‘time out’ to establish method of communicating to outside the theatre suite and that the equipment is working

  • Revision of local COVID-19 SOP to highlight neonatal teams’ discretion in attending theatre immediately

  • Signage on theatre doors to prevent incorrect entry in theatre suite and potential exposure of staff to COVID-19 after aerosol-generating procedures


In conclusion, we found that using a combination of point-of-care simulation and the FMEA tool led to the detection of safety hazards in local SOPs which have now been corrected.

Data availability statement

Data are available on reasonable request. Results from the simulation study and trust SOP are available from the supervising author.


We acknowledge the help of our obstetric teams, anaesthetic teams and midwives who aided in the running of the simulations and writing the SOPs. In particular, Dr Sally Harrison, Margaret Blott, Jennifer Woods and Dr Kate Sherratt.



  • Twitter @Sam_Curtis1

  • Contributors SC, RF and LE-K devised and carried out the simulation. SC wrote the manuscript with support from PN, RF and LE-K. All authors devised the failure modes and effects analysis. PN conceived the original idea and supervised the project. All authors reviewed and authorised the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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