Patient Safety and Medical Liability

Neonatal outcomes after introduction of a national intrapartum fetal surveillance education program: a retrospective cohort study

OBJECTIVE

To determine the impact of a multidisciplinary fetal surveillance education program (FSEP) on term neonatal outcomes.

METHODS

A retrospective cohort study of term neonatal outcomes before (1998-2004) and after (2005-2010) introduction of a FSEP. Clinical data was collected for all term infants admitted to a neonatal intensive care unit (NICU) in Australia between 1998 and 2010. Infants with congenital abnormalities were excluded. Neonatal mortality and severe neonatal morbidity (admission to a NICU, respiratory support, hypoxic encephalopathy) were compared before and after the FSEP was introduced. The rates of operative delivery during this time were assessed.

RESULTS

There were 3 512 596 live term births between 1998 and 2010. The intrapartum hypoxic death rate at term decreased from 2.02 to 1.07 per 10 000 total births. More neonates were admitted to NICU after 2005 (10.6 versus 14.6 per 10 000 live births), however fewer babies admitted to the neonatal unit had Apgar scores < 5 at five minutes (55.1-45.5%, RR 0.82, 95% CI 0.7-0.87); and rates of hypoxic ischemic encephalopathy fell from 36% to 30% (RR 0.83, 95% CI 0.76-0.90). There was no increase in rates of emergency in labour caesarean sections (11.7% pre versus 11.1% post, RR 0.95, 95% CI 0.95-0.96).

CONCLUSIONS

Introduction of a national FSEP was associated with increased neonatal admissions but a reduction in intrapartum hypoxia, without increasing emergency caesarean section rates.

The role of insurers in maternity safety

Adverse events in maternity care are frequently avoidable and litigation costs for maternity care are rising for many health services across the world. Whilst families for whom this injury was preventable suffer from this tragedy, there is an enormous loss of resource to healthcare in general. It is axiomatic that preventing avoidable harm is better for women, their families and society in general, and downstream this improvement should also reduce both litigation and costs. However, there are few initiatives that have reduced adverse clinical events in maternity services and fewer still that have demonstrated decreases in litigation costs. Where these data do exist, the involvement and engagement of insurers seem to have been crucial, but often unrecognized. Insurers could play a much broader role in preventing harm, and this article explores this potential.

The case for an electronic fetal heart rate monitoring credentialing examination

The Perinatal Quality Foundation has created an examination containing both knowledge-based and judgment questions relating to the interpretation of electronic fetal heart rate monitoring for credentialing all medical and nursing personnel working on a labor and delivery floor. A description of the examination and the rationale for its use throughout the United States is presented.

Interdisciplinary collaboration to maintain a culture of safety in a labor and delivery setting

A culture of safety is a growing movement in obstetrical healthcare quality and management. Patient-centered and safe care is a primary priority for all healthcare workers, with communication and teamwork central to achieving optimal maternal health outcomes. A mandatory educational program was developed and implemented by physicians and nurses to sustain awareness and compliance to current protocols within a large university-based hospital. A didactic portion reviewing shoulder dystocia, operative vaginal delivery, obstetric hemorrhage, and fetal monitoring escalation was combined with a simulation session. The simulation was a fetal bradycardia activating the decision to perform an operative vaginal delivery complicated by a shoulder dystocia. More than 370 members of the healthcare team participated including obstetricians, midwives, the anesthesia team, and nurses. Success of the program was measured by an evaluation tool and comparing results from a prior safety questionnaire. Ninety-seven percent rated the program as excellent, and the response to a question on perception of overall grade on patient safety measured by the Agency for Healthcare Research and Quality safety survey demonstrated a significant improvement in the score (P = .003) following the program.

The effect of malpractice claims on the use of caesarean section

Malpractice fears are believed to influence various aspects of obstetrical practice. They seem to have contributed in small part to the rising primary caesarean section rate, but have also played a considerable role in the downtrend in vaginal birth after caesarean statistics. The rising vaginal birth after caesarean section rate between 1981 and 1995 was interrupted by a spate of lawsuits associated with broadened indications for vaginal birth after caesarean section in conjunction with requirements for immediate clinician availability. These factors dramatically reduced the availability of hospitals and clinicians willing to offer vaginal birth after caesarean section. This reversal, however, has not diminished the demand for vaginal birth after caesarean section from various stakeholders in the name of patient autonomy, clinician beneficence and optimal care. Nevertheless, as long as stringent requirements remain for clinician attendance during vaginal birth after caesarean section, and as long as the spectre of preventable error and the lingering dread of lawsuits retain their hold on obstetrical practice, caesarean section trends are unlikely to change.

Closed medical negligence claims can drive patient safety and reduce litigation

BACKGROUND

Medical liability reform is viewed by many physician groups as a means of reducing medical malpractice litigation and lowering healthcare costs. However, alternative approaches such as closed medical negligence claims data may also achieve these goals.

QUESTIONS/PURPOSES

We asked whether information gleaned from closed claims related to medical negligence could promote patient safety and reduce costs related to medical liability. Specifically, we investigated whether physician groups have examined such data to identify error patterns and to then institute specific patient treatment protocols.

METHODS

We searched for medical societies that have systematically examined closed medical negligence claims in their specialty to develop specific standards of physician conduct. We then searched the medical literature for published evidence of the efficacy, if any, related to the patient safety measures thus developed.

RESULTS

Anesthesia and obstetric physician societies have successfully targeted costs and related concerns arising from medical malpractice lawsuits by using data from closed claims to develop patient safety and treatment guidelines. In both specialties, after institution of safety measures derived from closed medical negligence claims, the incidence and costs related to medical malpractice decreased and physician satisfaction improved.

CONCLUSIONS

Tort reform, in the form of legislatively prescribed limits on damages arising from lawsuits, is not the only means of addressing the incidence and costs related to medical malpractice litigation. As the experience of anesthesia and obstetric physicians has demonstrated, safety guidelines derived from analyzing past medical malpractice litigation can achieve the same goals while also promoting patient safety.

Patient safety series: obstetric safety improvement and its reflection in reserved claims

In reviewing outcomes that are associated with the implementation of a series of labor and delivery patient safety efforts from 2004-2009, we requested data on the number of related professional liability claims that were reserved by our insurance companies that are established with the specific objective of financing risks that emanate from their parent group or groups. While we restructured the manner in which we give care, required training modules, and provided simulations to our providers, our legal risk continued to be monitored independently and in parallel. Retrospective review of the number of cases for which money was held in reserve for claims demonstrated a 20% decrease per year, which was adjusted for delivery volume, over this time period. We believe that the improved care that resulted from our safety projects has led to this decreased legal risk.

Establishing a culture of perinatal safety in a community hospital

While unsafe behavior of frontline hospital staff, primarily physicians and nurses, is sometimes the proximal cause of adverse events, the critical importance of system-wide, hospital organizational factors is now being acknowledged(1,2). These organizational factors create the "safety culture" that influences the occurrence of these proximal failures.(3) The concept of safety culture originated in high-reliability organization theory, which was largely developed by a group of social scientists at the University of California at Berkeley who studied high-risk organizations that have achieved very low accident and error rates, for example, aircraft carrier flight decks, nuclear power plants and air-traffic control systems.(4-6) Safety culture refers to the enduring and shared beliefs and practices of organization members regarding the organization's willingness to detect and learn from errors.(7).

Of parachutes and patient care: a call to action

Obstetric caregivers are plagued with lawsuits alleging negligence for suboptimal outcomes. Some of those claims are unjustified, but many have merit. We are obligated to create systems designed to minimize the potential for errors that harm our patients. A variety of safety initiatives have been shown to improve patient outcomes in several centers in the United States, but it has been difficult to document the expected association between those results and reduced liability premiums. Furthermore, some individuals and institutions have been reluctant to adopt safety tools such as electronic fetal monitoring certification for all staff working on their Labor and Delivery floor, protocols for managing common clinical scenarios, simulation drills for dealing with uncommon dangerous events, and pre-procedure checklists because of the paucity of evidence based data documenting the effectiveness of those approaches. It is time to move forward with these and other safety initiatives in a serious national attempt to eliminate all preventable adverse patient outcomes in our specialty.

Benchmarking and patient safety in hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy are a major cause of morbidity and mortality worldwide. Reliable, published individual patient data from units and countries are lacking. Without these data, clinicians are unable to benchmark their incidence, treatments and outcomes, and patient safety is unable to be routinely assessed. Available data suggest that a notable proportion of the adverse events that occur with hypertensive disease of pregnancy may be preventable. Theory and practice indicate several methods that can offer the possibility of averting these preventable adverse events. These methods include benchmarking outcomes, standardisation of care processes, simulation, and enhancement of patient knowledge. However, data on optimal methods to enhance patient safety and quality of care of pregnant women with hypertensive disease remain limited, and further research is required.

VBAC: a medicolegal perspective

History has always been a series of pendulum swings, and there is perhaps no better example in obstetrics than that of vaginal birth after cesarean. Vaginal birth after cesarean (VBAC) rates rose steadily in the early 1990s. However, VBAC rates have declined dramatically over recent years, while the cesarean delivery rate has continued to rise unabated. Many physicians and hospitals are no longer offering trial of labor after cesarean, largely because of medicolegal concerns. This article explores the medical and legal risks of trial of labor after cesarean.

Patient safety in obstetrics--the Hospital Corporation of America experience

We report an update on obstetric patient safety efforts and results in the nation's largest obstetric health care delivery system. The application of principles advocated by the Institute of Medicine a decade ago has resulted in reduced adverse outcomes, as reflected by claims experience. Particular progress has been made in standardization and documentation of critical processes, establishment of national quality benchmarks, reduction in elective deliveries <39 weeks' gestation, and reduction in fatal postcesarean pulmonary embolism. Our experience provides a useful blueprint for similar progress in other health care systems.