Battling the Obstetric Malpractice Crisis: Improving Patient Safety, Part 2

Peter S. Bernstein, MD, MPH


December 15, 2005

Before physicians can hope to see reform with respect to how the legal system in the United States deals with poor medical outcomes, they must first be seen as leading the campaign to improve patient safety. In Part 1 of "Battling the Obstetric Malpractice Crisis: Improving Patient Safety,"[1] we explored the idea that the first step in the process is to begin by acknowledging that medical errors are inevitable and that often it is not a single error by a single individual that leads to a poor outcome, but rather a series of small events involving a number of individuals that leads to the medical error that results in harm to a patient.

So what exactly should the medical profession, and obstetricians in particular, be doing?

In 2003, the American College of Obstetricians and Gynecologists weighed in when it issued the Committee Opinion on "Patient Safety in Obstetrics and Gynecology." This document outlines 7 objectives to be adopted by providers and healthcare organizations in an effort to reduce preventable poor outcome.[2] 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

Underlying these recommendations is the acknowledgment that medical errors occur. Even the most well-trained and skilled providers make mistakes. Once we accept this, it becomes clear that what is needed is a network of support systems designed to reduce the chance that providers will make an error, and if they do make an error, that the consequences will be minimized to the greatest extent possible.

Thus, in Part 2, some examples in obstetrics are explored that demonstrate a few of the objectives outlined in the Committee Opinion.

So how does one develop a culture of safety in obstetrics? The first step is to consider that no one practices obstetrics alone; gone are the days when the physician and the nurse were alone in a delivery room with a laboring patient. Everyone in the labor and delivery suite has to take responsibility for every patient on the floor. Thus, if one physician is preoccupied with one patient, another physician will be available to step in -- without being asked -- to keep track of the first physician's other laboring patients. Or, before one provider allows his patient to continue to labor with a less than perfect fetal heart rate tracing, another provider will give an unsolicited consultation on the tracing.

This style of practice applies not only to the physicians but to everyone on the labor floor; the individual with the critical piece of information that might prevent a poor outcome may be the nurse, the intern, or the nursing assistant. The environment on the labor floor must be one in which anyone can step forward without hesitation to voice an opinion or share an observation as part of an effort to improve patient safety. This is part of the "Team Training model" championed by organizations such as the Risk Management Foundation of the Harvard Medical Institutions.[3]

Improving communication in ACOG's Committee Opinion largely refers to better communication with patients generally and, particularly, to disclose unexpected outcomes. Thus, it refers to the process of obtaining informed consent for a procedure as not just a perfunctory exercise that must be done but one in which the procedure is carefully explained as are the risks, benefits, and alternatives to the procedure. Care is taken to make sure the patient understands and all questions are answered.

Providers often feel that they do not have time to have these sorts of detailed discussions with patients; that such conversations cannot occur during a fetal bradycardia, for example, when a cesarean delivery is urgent. That is why preparation for such discussions needs to be done before the patient arrives on the labor floor and why such programs as the group prenatal care model championed by the Centering Pregnancy and Parenting Association[4] may be so important for improving patient safety. This model of care allows providers to be just as productive as they are when they offer traditional prenatal care but to spend roughly 10 times the amount of time with their patients over the course of their pregnancies, which allows more to time to optimize communication . The need for improved communication with patients was again highlighted in a more recent ACOG Committee Opinion.[5]

Methods to improve communication should not be limited to communication with patients but should also include communication between physicians, nurses, midwives, residents, pharmacy staff, etc. Thus, systems need to be developed in addition to the Team Training kinds of models discussed above that incorporate such technological solutions as problem-oriented electronic medical records (both inpatient and outpatient records) to optimize communication between the office, the antepartum testing unit, and the labor floor.[6] Electronic physician order entry systems to reduce prescribing errors are another example of a technological solution.

Healthcare systems also need to be able to take a careful look at untoward outcomes with an eye to addressing systems problems. This means developing multidisciplinary committees that dissect every poor outcome and every near-miss poor outcome -- not to find someone to whom blame for the outcome can be assigned, but to address systems issues so that similar events may be prevented if at all possible. To do this, these groups must be able to work together in a way that providers can trust them to be nonpunitive and such that the provider will be forthcoming and honest when asked to report on an adverse event so that it can be studied effectively. Additionally, the meetings of these groups and the data they collect need to be nondiscoverable to the legal system so that the groups can thoroughly investigate the events without fear of creating problems for their colleagues, their institutions, or themselves. This is not a means to cover things up but a way to improve patient safety for everyone. The New York State ACOG program to investigate maternal mortalities is an example of this kind of program.[7]

And finally, we need to focus on efforts to improve how providers perform when they encounter one of the rare emergencies that can have devastating impacts on the mother and newborn. Medical simulation may be an important way to address this issue. Medical simulation is a relatively new field that has been adapted from the aviation industry as a way to prepare healthcare providers to deal more effectively with rare emergencies. The techniques in this field are now being shown to be effective for training nurses and physicians about how to deal with potentially catastrophic events such as shoulder dystocia.[8] One day soon we may find it useful to have all labor and delivery staff routinely practice mock "codes" in simulated environments in order to maintain and improve their skills as a team to function optimally during obstetric emergencies.

Improving patient safety has to be the dominant focus of obstetrics in the coming years. And it should not be something that is resisted by physicians. "To do no harm" is a part of the oath that most of us took en route to becoming physicians. Thus, we fail to live up to our oath any time a patient has an untoward outcome while under our care. And these efforts are not only in the interests of our patients; they will also benefit us and the medical profession as a whole in the long run.


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