Battling the Obstetric Malpractice Crisis: Improving Patient Safety, Part 1

Peter S. Bernstein, MD, MPH


October 31, 2005

Lawsuits against obstetricians contribute disproportionately to the medical malpractice crisis in the United States. Much of this is clearly the result of a flawed legal system, and it goes without saying that the current system of dealing with medical malpractice needs to be reformed, and reformed soon. The consequences are readily apparent, with unnecessary tests and procedures contributing to increasing healthcare costs, skyrocketing insurance premiums, shortages of obstetric care providers in many areas of the country, and dramatically falling numbers of students choosing a career in obstetrics and gynecology.

Although much is unfair and capricious in how these untoward outcomes are handled by the legal community in the United States, it is not enough for the medical profession to simply demand reform of how medical malpractice claims are handled. The medical profession will forever be seen by the American public as trying to protect its own pocketbooks, unless it is clear that they are out in front in the campaign to improve patient safety. Given the reports of surprisingly high rates of medical errors, it is equally clear that there is much that the profession can and must do to reduce medical errors and promote patient safety.[1]

Toward this end, we must recognize that even the most well-meaning, best-trained, and most skilled physicians make errors. We are all only human and are frequently working under stressful circumstances. Errors usually do not occur because we are inept or malicious; they occur because we have not built systems of care to prevent these errors from happening or at least to catch them before they cause patient harm.

In cases that I have reviewed, seldom is it the fault of a single person that a bad outcome occurred. Typically, it is the result of a confluence of factors. Consider this hypothetical but very plausible example: A woman presents for her first labor at term. She has an uneventful labor until she is 8 cm dilated when the fetal heart tracing becomes worrisome. No further investigation of the fetal heart tracing is done (eg, a fetal scalp pH or fetal oxygen saturation monitoring). A cesarean section is performed, and a baby is delivered with normal Apgar scores and normal cord pH.

In her second pregnancy, suppose the patient's uterus ruptures after an induction of labor is performed or, alternatively, that she opts for a repeat cesarean delivery and there is a bladder injury or the uterine incision extends into the uterine artery and she requires a transfusion and a hysterectomy. Is it the fault of the surgeon that there was an extension of the uterine incision? Possibly. What about the obstetrician who may have been too quick to give up on a vaginal delivery in the first pregnancy? What about the systems in the hospital for supporting that physician managing the patient's first labor? How easy was it to perform a scalp pH? Who was available to consult on a nonreassuring fetal heart tracing? Was the first cesarean performed because it was 4 AM and the physician caring for the patient was tired and just wanted to get the delivery over with so he could get a few hours of sleep? And during the second pregnancy, who was available to assist if there was a problem during the repeat cesarean delivery?

Consider another scenario: Suppose the patient did not have a complication during her second cesarean but failed to get the tubal ligation that she wanted because the required paperwork had been left in the office by mistake and that she had a third pregnancy, conceived despite her using oral contraceptive pills, which was complicated by placenta previa/accreta. In that pregnancy, suppose she delivered a preterm baby at 30 weeks of gestation and nearly lost her life during her cesarean/hysterectomy.

In all these scenarios, the problems encountered are not unusual and are not the result of any one negligent physician. It can be assumed that all the care was delivered by well-meaning and competent staff, who by and large may have made correct decisions at every point in the course of this patient's care. Instead, if the systems supporting the providers were better designed, the course of the patient's care might have been better and the poor outcomes averted.

To address the issue of medical errors, we need to begin by trying to remove the pejorative connotation from the term "medical error." If we can do that, we may be able to review these cases with an eye to building systems that prevent the bad outcomes. For example, is it difficult to get a scalp pH in the middle of the night? Is it easy for a provider to get a consultation on interpreting a fetal heart tracing? Maybe even better yet, why can't systems be put in place so that providers do not have to ask for consultations on fetal heart tracings, but instead those consults are provided automatically? What if that provider is excessively fatigued or is responsible for several patients in labor? Who can step in to assist? Quality improvement committees need to be able to address all these issues as part of an effort to reduce medical errors. If the provider is overwhelmed by too many patients in labor at the same time, can't the system be designed so that assistance is automatically provided without waiting for the provider to call for it? Anticipating the situation in which a medical error may happen and addressing it before it occurs is superior to having to deal with it after it does.

Given the current medical-legal climate, gone are the days when physicians manage patients alone in a delivery room with a nurse. Even the best physician will encounter circumstances in which having someone looking over his or her shoulder may avert a poor outcome. Averting that poor outcome not only benefits the patient but also the physician, and the entire profession.

The key to preventing poor outcomes is scrupulous examination of both those outcomes that have occurred and those that almost occurred. Attention must be paid both to the proximate causes and the not so proximate causes. Then investments must be made in the system so that if a similar situation occurs, procedures are in place to prevent it. This will hopefully minimize the risk of a patient ever being put in a position of having to face the consequences of a medical error.

It is this sort of logic that led the American College of Obstetricians and Gynecologists in 2003 to issue a Committee Opinion on "Patient Safety in Obstetrics and Gynecology,"[2] which outlined 7 objectives to be adopted by providers and healthcare organizations in an effort to reduce preventable poor outcome. They are as follows:

  1. Develop a commitment to encourage a culture of patient safety

  2. Implement recommended safe medication practices

  3. Reduce the likelihood of surgical errors

  4. Improve communication

  5. Identify and resolve system problems

  6. Establish a partnership with patients to improve safety

  7. Make safety a priority in every aspect of practice

In the next issue, I will explore some of these objectives with examples of how they can potentially be adopted.


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