New strategies help reduce OB errors

Every risk manager worries about the obstetrics unit, where the number of adverse events may be small but the scope of the tragedy and liability can be huge. Health professionals at Yale School of Medicine in New Haven, CT, have addressed the problem head on by instituting a series of patient safety improvements that decreased the rate of adverse events by about 60% over 2.5 years, while improving the staff's own perception of the overall safety climate by 30%.

The effort at Yale was spurred by claims data from the school's insurer that showed obstetrics claims accounted for an inordinately large share of claims dollars and the trend was worsening, says Edmund F. Funai, MD, associate professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at Yale. He notes that an estimated 44,000 to 98,000 Americans die in hospitals each year as a result of errors, and about half of all medical errors are linked to communication errors and system failures. Obstetrics has lagged behind other specialties in attempts to improve safety because perinatal adverse events are relatively uncommon and usually unexpected, because they normally occur in previously healthy patients who are anticipating good outcomes, he says.

Funai and his team designed and implemented clinical patient safety interventions at Yale-New Haven Hospital. These included communication training, standardizing interpretation of fetal monitoring, and creating a novel staff role: the patient safety nurse. The 60% drop in adverse events and the improvement in the staff's perception of safety were determined by tracking and analyzing 14 markers for adverse outcomes and a survey given by a third party.

Funai says Yale put together a team that included obstetricians, risk managers, and several consultants specializing in patient safety and obstetrics. The team soon identified a number of key issues, including management of labor, interpretation of fetal monitoring, and the use of high-risk medications such as oxytocin. However, the common link in most of the threats to patient safety in obstetrics is a breakdown in communication, Funai says. That break usually involves failure to recognize the severity of a given situation or condition, often involving a newborn's status, he says.

Communication issues are only going to increase in response to restrictions on resident work hours, Funai says. Patients are increasingly handed off from shift to shift, and more attending physicians are practicing shift medicine, he says. "There is just more opportunity for errors in patient care," Funai says. "Everything we can do to standardize care and facilitate communication will make a big difference."

Improving communication should be a primary focus of any effort to improve obstetrics safety, says Susan R. Chmieleski, APRN, FASHRM, JD, vice president of risk management and client services with Darwin Professional Underwriters in Farmington, CT. Darwin has focused on improving patient safety in obstetrics in recent years, and she says that a root-cause analysis of most errors in this specialty will find that a communication breakdown is at least a contributing factor, if not the primary cause.

It's not as easy as saying that everyone should communicate better and therefore there won't be patients harmed by errors, Chmieleski says. "But what we find when we look at the data on obstetrics errors is that no matter what actually went wrong with a medication error, or failure to take notice of a decline in the patient's condition, or failure to take the right action in a timely manner, usually there is a communication failing involved," she says. "If someone had said the right thing in the right way at the right time, a tragedy might have been averted."

Chmieleski also recommends that risk managers conduct patient safety rounds in the obstetrics unit. A systematic check on operations in this critical unit can head off potential problems, she says. (For more on how to conduct obstetrics safety rounds, see article, right.)

Patient safety nurse is new

A novel part of the Yale effort was the addition of an obstetrics patient safety nurse whose sole responsibility is to monitor the overall patient care and ensure that all parties are communicating.

This full-time nurse has broad responsibilities that include being present for patient handoffs and overseeing the overall care of patients, but she has no bedside clinical responsibilities, Funai says. The nurse in this role has a clinical background, which is an important qualification, but any hands-on patient care would be a distraction and divide her attention, he says.

The position currently is filled by one person who works full time, so the patient safety nurse is not available 24 hours a day. The hospital had to take on a new full-time equivalent to fill the role, but the hospital's insurer provides funding that covers the cost of the new position.

OB safety rounds can reduce errors

Patient safety rounds can be a good idea throughout any health care facility, but the obstetrics unit is where you might see a significant impact from this effort, says Susan R. Chmieleski, APRN, FASHRM, JD, vice president of risk management and client services with Darwin Profes-sional Underwriters in Farmington, CT.

Chmieleski offers these tips for conducting patient safety rounds in obstetrics:

  • Develop a checklist. This checklist can include the most important policies and procedures you have instituted for obstetrics, which could be everything from how drug orders are entered to whether the infants have abduction deterrent devices. Remember that you can ask staff about their knowledge of these policies and procedures, in addition to noting what you can observe when you visit.
  • Include other hospital leaders in your rounds. It is fine, and sometimes desirable, for the risk manager to conduct obstetrics rounds on your own sometimes. But on other occasions, invite other hospital leaders to round with you. Good candidates are the chief of obstetrics, the head of anesthesia, nursing supervisors, and quality improvement leaders.
  • Keep a low profile. Don't draw a lot of attention to your visit. Your goal is to see the obstetrics unit as it typically operates, not to have everyone shape up because they know you are inspecting them. If others are rounding with you, keep it to just two or maybe three at a time. If more than that are participating, they should go in different groups of two or three at a time.
  • Report back to the unit. Let the obstetrics unit staff and physicians know what you observed, both the good and the bad. Don't forget to praise the good work you saw and compliment the staff on adhering to policies and procedures.

In addition, the hospital wanted to standardize many of the typical care scenarios in obstetrics, such as the administration of commonly used medications. The medical literature allows a wide range of dosing for some drugs, for instance, so Yale developed 34 new policies and procedures that standardize when and how drugs are to be administered in obstetrics, as well as clearly defining the chain of command and how to communicate concern.

Getting buy-in from individual physicians was a big task, Funai says, because they naturally will resist any idea of "cookbook medicine." He helped convince his fellow physicians, in part, by reminding them of a fact learned in the airline industry: Most accidents happen when you're extremely busy or when your workload is very light. In the middle, most people perform well, but at the extremes, they can benefit from a set of standardized procedures.

Yale also clarified the steps that staff members should take when they are concerned about a patient but don't agree with the care being provided. The policies and procedure outline in a step-by-step fashion how to proceed up the chain of command. They emphasize that Yale expects staff to do this and that it is not considered troublemaking.

"After taking these surprisingly simple steps to address safety, both patients and staff report that the care is much more seamless and better organized," Funai says. "The staff is more comfortable and empowered to communicate their concerns about a patient. A comfortable staff often leads to more successful patient outcomes."

Sources

For more information on reducing liability in obstetrics, contact:

  • Susan R. Chmieleski, APRN, FASHRM, JD, Vice President, Risk Management and Client Services, Darwin Professional Underwriters, Farmington, CT. Telephone: (860) 284-1954. E-mail: schmieleski@darwinpro.com.
  • Edmund F. Funai, MD, Associate Professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT. Telephone: (203) 785-6885. E-mail: edmund.funai@yale.edu.