Two Studies Describe Approaches Shown to Reduce Obstetrical Errors

Laura Beil

February 04, 2008

February 4, 2008 (Dallas) — Two studies presented here during the Society for Maternal-Fetal Medicine 28th Annual Meeting have found strategies that can reduce obstetrical errors, although the results may not become apparent until a year after implementation.

In the first study, researchers from Yale-New Haven Hospital described a sweeping series of changes implemented after their malpractice premiums almost doubled between 2002 and 2004. Beginning in late 2004, the hospital introduced a comprehensive protocol designed to reduce medical errors. The strategy had 6 components: independent review of the service, the creation of a full-time patient safety nurse, standardizing common procedures such as oxytocin administration, mandatory crew resource management training to improve communication among staff, adoption of standard terminology in interpreting fetal heart monitoring, and multidisciplinary oversight by a patient safety committee.

Before the study began, the hospital experienced a 3% error rate, said Edmund Funai, MD, from the Yale University School of Medicine, New Haven, Connecticut, noting that their level was consistent with other published rates. The number was cut in half, to 1.5%, about 2.5 years after the new strategy was implemented (P = .02).

In addition to the reduction in errors, the hospital saw its malpractice premiums fall from about $95,000 annually per physician to $53,000, although Dr. Funai was quick to point out that solely crediting the program would be difficult.

Among the most notable components of the strategy was the hiring of a full-time patient safety nurse, who maintained a high-profile position at the hospital by reviewing cases and serving as a central contact for the staff. In addition, the hospital required a 2-challenge rule, which borrows from a practice used in the aviation industry. The 2-challenge rule requires hospital personnel to question any situation they think jeopardizes patient safety and then do so a second time if the circumstances do not change.

"We all practice better medicine when nonphysician staff [members are] empowered to speak up," Dr. Funai told Medscape Ob/Gyn & Women's Health. Hospitals who would like to duplicate the strategy, he said, "need visible and enthusiastic physician leadership."

A second study, from researchers at Lehigh Valley Hospital in Allentown, Pennsylvania, also showed that implementing even 1 component of this strategy — crew resource management — can also improve safety records by encouraging better communication. The Lehigh researchers found a drop in errors, though the rate did not begin to fall until more than 6 months after implementation.

Although the new data from Yale are encouraging, it is difficult to know how much this approach could be generalized to other hospitals that would not have the resources of a large teaching institution, said George Macones, MD, from Washington University School of Medicine, Saint Louis, Missouri. Still, he said, such studies provide valuable insight into ways to improve patient safety.

"Big events are uncommon, but the stakes are very high," said Dr. Macones, who was not involved in the study.

Another researcher not involved in the study, Jennifer Bailit, MD, from the MetroHealth Medical Center at Case Western University in Cleveland, Ohio, also told Medscape Ob/Gyn & Women's Health that the profile of each individual hospital may determine the degree to which the Yale program would work. For instance, she said, "many hospitals don't have someone dedicated to safety in obstetrics."

During the presentation, Dr. Funai pointed out that, regardless of the institution, poor communication is the top cause of medical mistakes. And although only a fraction of patients are actually injured, perhaps 10-fold more experience close calls. He told his colleagues, "It's the entire iceberg that is the target for change."

The study was funded by the malpractice carrier MCIC. Dr. Funai, Dr. Macones, and Dr. Bailit have disclosed no relevant financial relationships.

Society for Maternal-Fetal Medicine 28th Annual Meeting: Abstract 54, presented February 1, 2008; abstract 81, presented February 2, 2003.

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