Engaging in patient safety, quality improvement, and risk reduction work takes guts to confront our shortcomings and the tension this creates. We may be wary of forming partnerships with the myriad of individuals and groups who have entered this arena.
To get you started, here is a sampling of potential partners and resources.
The Agency for Healthcare Research and Quality (AHRQ)
The Agency for Healthcare Research and Quality (AHRQ) is the lead federal agency charged with improving the quality, safety, efficiency, and effectiveness of health care for all Americans.
As one of 12 agencies within the Department of Health and Human Services, AHRQ supports health services research that will improve the quality of health care and promote evidence-based decision-making. Their mission, scope, and strategies are broad, and much of their rich resources are applicable to risk reduction, patient safety, and family-centered perinatal care.
One example is PSNet (Patient Safety Network), a website of continuously updated, annotated, and carefully selected collection of patient safety news, literature, tools, and resources. Their website contains excellent resources.
The American College of Nurse-Midwives (ACNM)
The American College of Nurse-Midwives (ACNM) has informed members that the most frequent claims brought against their members involve:
- Failure to initiate timely referral to an obstetrician once an adverse event has presented itself, and appropriate management if the event is outside the midwife's scope of practice and expertise.
- Failure to properly monitor and interpret electronic fetal monitoring. The highest awards occurred in this category.
The ACNM has a position statement, Creating a Culture of Safety in Midwifery Care, and a number of publications addressing patient safety, quality improvement, and risk reduction.
The American College of Obstetricians and Gynecologists (ACOG)
The American College of Obstetricians and Gynecologists (ACOG) reports "a continuing negative trend" in their 2006 Survey on Professional Liability.
This survey, similar to those in 1983, 1985, 1987, 1990, 1992, 1996, 1999, and 2003, addresses the impact that professional liability is having on the practice of obstetrics and gynecology.
Selected data as reported in ACOG Clinical Review, March-April 2007
- 8,294 respondents
- 77.7 percent provide both obstetrics and gynecological care
- Average doctor performed 11.4 NSD, 0.8 VBAC and 4.3 C/S per month
- 89.2 percent respondents had at least one professional liability claim during their career or an average of 2.62 claims per OB/GYN doctor
- 62.1 percent were obstetrical claims
- 37.9 percent were gynecological claims
- 67.4 percent of claims were dropped or settled on behalf of the OB/GYN doctor
- 20.1 percent settlement and payment in advance of trial
- 10.2 percent payment after jury or court verdict
- 3.4 percent payment after alternative dispute mechanism
- Family practice doctors were named as co-defendants in 2.9 percent of claims
- Nurse-midwives were named as co-defendant in 3.8 percent of claims
- Nurses were named as co-defendants in 12 percent of claims
- Ob/gyn residents were named as co-defendants in 15 percent of claims
Findings from 4,184 obstetrical claims
- Neurologically impaired infant (30.8 percent)
- Average payment for these claims was $1,150,687
- Stillbirth/Neonatal death (15.8 percent)
- Shoulder Dystocia or Brachial Plexus Injury associated with 15.7 percent of claims
- 10.9 percent of claims involved EFM
- Respondents named actions of non-MD providers as factor in 5.8 percent claims
- Respondents named actions of ob/gyn residents as factor in 8.6 percent of claims
|Practice change||Reason: affordability and availability of insurance||Reason: fear of liability claims or litigation|
|Stop obstetrical practice||7.2%||8.3%|
|Increase in cesarean deliveries||28.5%||37.1%|
|Decrease in deliveries||11.7%||14.5%|
|Decrease no. of high-risk
|Decrease gyn surgical procedures||12.6%||16.4%|
|Stop major gyn surgery||4%||4.9%|
|Stop all surgery||2.1%|
Attorneys and Claims Managers
Attorneys and claims managers have information, advice, and observations of trends to share with us:
- It is common that over 50 percent of a hospital's risk management budget is spent in OB; over 50 percent of insurance company losses are obstetrical cases.
- Documentation must be consistent between RNs, CNMs, and MDs, and prove absolutely "no abandonment." Record TIME as well as the date in all notes because the timing of the injury becomes crucial in many cases.
- Do not editorialize in the medical record. What belongs in a chart are your FINDINGS.
- Plaintiffs' counsel have become specialized (e.g. obstetric cases) and sub-specialized (e.g. shoulder dystocia cases), and their cases are much better prepared.
- Plaintiffs' counsel have vastly increased resources for case preparation and recruitment of legitimate experts with good credentials.
- The use of professionally prepared multimedia presentations of technical and scientific information, as well as "A Day in the Life" stories abou the plaintiff, is increasing.
- Successful plaintiffs' counsel carefully screen cases and focus on those with major injury and deviations from standards of care that are almost irrefutable.
- Non-physicians (RNs, CNMs, genetic counselors) who were rarely named in lawsuits in the past are increasingly named as defendants. They can appear very distraught, fearful, less confident, and less experienced than MDs in the courtroom.
- There are many more and more pre-trial settlements; juries are unpredictable; it is extremely difficult to defend a case when there were deviations from the standard of care or there is inadequate documentation of adequate care; and the cost of defending cases has steadily increased.
- Awards have become proportional to the magnitude of the injury, not to the presence or absence of negligence.
- Settlements/verdicts are in the multimillion-dollar range.
- Some defense counsel perceive that there is a reversal of the burden of proof in medical negligence cases. Once the jury notes a major injury, the defendants are often pressed to disprove negligence to the jury's satisfaction rather than the reverse.
- In some settings, health care professionals no longer have the standing in the jury's eyes that they once did.
- It is clear that many doctors, nurses, midwives and counselors do not understand the concept of 'the standard of care' and are unfamiliar with the guidelines, technical bulletins, peer review articles, textbooks, and other things that may be used to establish a standard of care in a case.
- The internet has eliminated the ability to defend a local or regional standard of care. Everyone must demonstrate that they know the national standard of care for a given situation and explain how they exerted due diligence to meet it, given the resources available to them.
- There are an increasing number of cases regarding failure to diagnose cancer, especially breast cancer.
The Institute for Healthcare Improvement (IHI)
The Institute for Healthcare Improvement (IHI) is a not-for-profit organization leading the improvement of health care throughout the world. The Institute helps accelerate change in health care by cultivating promising concepts for improving patient care and turning those ideas into action. Their aim is to improve the lives of patients, the health of communities, and the joy of the health care workforce.
IHI works toward:
IHI reports that according to industry research, five recurring clinical issues are responsible for the majority of perinatal harm and the associated obstetrical liability:
- Failure to recognize non-reassuring fetal status
- Failure to effect a timely cesarean birth
- Failure to properly resuscitate a depressed baby
- Inappropriate use of oxytocin and misoprostil
- Inappropriate use of vacuum and forceps
Reviews of perinatal care have consistently pointed to failures of communication among the care team and documentation of care as common factors in adverse events that occur in labor and delivery. They are also prime factors leading to malpractice claims.
The four key components of IHI's current perinatal efforts are:
- The development of reliable clinical processes to manage labor and delivery
- The use of principles that improve safety (i.e., preventing, detecting, and mitigating errors)
- The establishment of prepared and activated care teams that communicate effectively with each other and with mothers and families
- A focus on mother and family as the locus of control during labor and delivery
The following can be downloaded from the IHI website:
- The white paper Idealized Design of Perinatal Care
- The Perinatal Trigger Tool, which provides instructions for conducting a retrospective review of patient records using triggers to identify possible adverse events causing any physical harm to the infant or mother
- Pertinent perinatal improvement literature
The Institute of Medicine (IOM)
The Institute of Medicine (IOM) of the National Academies provides science-based advice on matters of biomedical science, medicine and health. The Institute works outside the framework of government to ensure scientifically informed analysis and independent guidance. The IOM's mission is to serve as adviser to the nation to improve health.
The Institute provides unbiased, evidence-based, and authoritative information and advice concerning health and science policy to policy-makers, professionals, leaders in every sector of society, and the public at large. They have produced 29 reports from 1990 to 2006 on women's health issues but have not directly addressed perinatal care in this country.
IOM describes our practice environment as a place in which there is "more to know, more to do, more to manage, more to watch, and more people involved than ever before. Faced with such rapid changes, the health care delivery system has fallen far short in its ability to translate knowledge into practice and to apply new technology safely and appropriately" and concluded that "the burden of harm conveyed by the collective impact of all our healthcare quality problems is staggering." (Chassen et al, 1998)
As a result of this work, an urgent call for fundamental change to close the quality gap was made. Eight years later, the IOM expressed frustration with the slow pace of improvement despite the body of knowledge and resources that have become available in the interim. Why?
The IOM concluded that the current system is:
- Fragile, voluntary and consensus-based, and therefore inherently conservative of the status quo and unlikely to produce bold change
- Controlled by a limited number of stakeholders who are not inclusive and inherently conservative of the status quo
- Accommodating to limited measures with significant gaps but not to comprehensive programs
- Wasteful and inefficient, with duplications and inconsistencies
- Inadequately interested in the public good
The Joint Commission
The Joint Commission (formerly referred to as JCAHO or "Jayco") is well known to most of us. Its mission is to "continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations."
Cases considered reviewable under the Joint Commission's Sentinel Event Policy are "any perinatal death or major permanent loss of function unrelated to a congenital condition in an infant having a birth weight greater than 2500 grams." The Joint Commission has compiled a list of recommendations related to organizational culture and communication as well as risk reduction strategies identified by hospitals during their root cause analysis of sentinel events.
Communication is cited as a root cause of perinatal death and injury in over 80 percent of cases, leading all other causes. - JCAHO Root Causes of Perinatal Deaths and Injuries, 1995-2004
Despite the health care system's dependence on team coordination and communication to achieve optimal outcomes, disciplines rarely engage in joint training. - Louis P. Halamek MD, Stanford School of Medicine, 2003
Sentinel Event Alert Issue #30: Preventing Infant Death and Injury During Delivery identifies root causes and risk reduction strategies, makes recommendations, and cites references. This document is frequently cited, and all obstetrical physicians, nurses, and midwives should be familiar with it. This sentinel event-related data demonstrates the need to continue to address these serious perinatal adverse events. This data also supports the importance of establishing national patient safety goals. By identifying causes, trends, settings and outcomes of sentinel events, the Joint Commission can provide critical information in the prevention of sentinel events.
The National Practitioner Data Bank (NPDB)
The National Practitioner Data Bank (NPDB) is a federally-maintained clearinghouse that maintains data on health care provider conduct. NPDB information can be helpful in following national trends.
- Obstetrics-related cases accounted for 8.1 percent of all physician-malpractice payment reports to NPDB.
- The median award reported for a childbirth-related claim was $2.5 million between 1997 and 2003, the highest of any specialty.
- NPDB reported an increase in 2003 and 2004 in the number of payments on behalf of nurses (RN, CNM, CRNA, CNS, NP). This group of nurses is responsible for only a small fraction (1-2 percent) of all payouts reported to the NPDB.
For more information on the Obstetric Safety Initiative, or to offer suggestions or additions to this site, contact us.