Team investigates OB adverse events

The medical liability response model being implemented in the OB units of five Ascension Health hospitals model emphasizes the need for clinicians to report all events that could result in a lawsuit.

Encouraging clinicians to report the event is crucial to providing a quick and effective response from a specially trained team, says Christine K. McCoy, JD, the system's vice president of risk management.

"We like to think that nurses and physicians will report these incidents to risk management every time, but we know that doesn't always happen," McCoy says. "Our caregivers know that there are certain triggering events that we absolutely want to know about. They don't mean that any error was involved necessarily, but they are unanticipated outcomes that we need to immediately look at and respond to them. The patient is going to want to know what happened, and it is our obligation to inform them."

When risk management learns of a triggering event such as shoulder dystocia resulting in a brachial plexus injury or APGAR scores below 3 at 5 minutes, the "OBERT" team responds. OBERT stands for Obstetrical Event Response Team, headed by the lead physician and including the lead nurse and representatives from risk management and quality. Others, such as a pediatrician or chaplain, might be included in some situations.

"We're training them in root cause analysis and improving the way they investigate events after they occur," McCoy says. "They learn to be situation managers. They can help coach and prepare their clinicians when they need to communicate with families after an adverse event."

The OBERT team begins the investigation immediately and starts planning for communicating with the family. Ascension Health uses the term "coordinated communication" to describe its approach. "We're trying to get away from the word 'disclosure,'" McCoy says. "When we started training physicians on a more standardized approach to communication, we found that 'disclosure' has a negative connotation to it. They're fearful of it. It sounds to them like they're admitting guilt or taking the blame for what happened, and that's not always the case."