Fetal distress a common OB claim

Miscommunication among the clinical team and substandard clinical judgment are among the most common causes of patient injury leading to obstetrics (OB) claims, according to "2010: Annual Benchmarking Report, Malpractice Risks in Obstetrics" released recently by Crico Strategies, the medical malpractice company owned by and serving the Harvard medical community in Cambridge, MA.

The company focuses on a data-driven approach to claims management and patient safety, and the report is based on an analysis of more than 800 OB cases from the office setting and the Labor and Delivery unit, from prenatal management to intra- and postpartum care. Most of these cases name an attending obstetrician who performed a vaginal delivery (or emergency cesarean section) after a prolonged second stage of labor.

"Purely from a numbers standpoint, OB cases are still relatively rare. But the emotional, physical, and financial impact on both the patient and the provider is tremendous," says Gretchen Ruoff, MPH, CPHRM, program director of patient safety services with Crico Strategies. "So even if you are looking at a relatively small number of cases, it is of critical importance to roll up your sleeves, take a close look, and really understand them so you can take action in your present day environment."

Ruoff cautions that the cases resulting in OB claims are only the tip of the iceberg. A close analysis of those claims will reveal common problems that most likely are affecting many OB patients who escaped injury or for other reasons did not pursue a claim. "You look at the common threads in those OB claims and then look under the surface to see how those are occurring in other cases, too. Then you see that the simple number of OB malpractices can be deceptive, that there is more of a problem than those cases alone," she says.

Most prevalent in the study are cases whose allegations involve mismanagement of second stage labor, operative vaginal deliveries, or prenatal care, Ruoff says. Injuries ranged from the emotional distress of a stillbirth or a severely compromised infant to the tragedy of a maternal death. Analysis reveals that plaintiffs experiencing injuries primarily cite communication failures, judgment lapses, and faulty technique as the reasons behind their injuries and their malpractice cases. (For the full report, go to www.rmf.harvard.edu. The report will be on the right side of the page. Click on the "Read" icon next to the benchmarking report. For other obstetrics information and guidelines, select "high risk areas" at the top of the page. Then choose "obstetrics.")

Most perinatal claims in the study cite missteps in judgment and communication during the second stage of active labor, which resulted in delays in the response to fetal distress, Ruoff notes. The most troublesome cases involve failures in clinical judgment fueled by "the loss of individual perspective and the lack of a collaborative discussion," the report says. "Together, these factors hinder obstetrical team members' recognition of fetal distress indicators, especially in a slowly declining situation," the report explains. "Often, the clarity of hindsight reveals that signs of distress were present, but providers isolated in one-on-one labor coaching, or navigating evolving priorities and changing shifts, struggled to maintain the awareness required for accurate decision making.'

The report recommends electronic fetal monitor (EFM) training, followed by regular opportunities for practice, as critical for effective translation of the baby's "language," which can indicate when it is in distress. Interdisciplinary training also is crucial, the report says."Individuals with strong teamwork skills are less susceptible to loss of perspective, better suited to facilitate action on often-veiled indicators of distress, and less vulnerable to preventable patient harm and allegations of malpractice," the report says. "At the height of expectations, when patient, family, and providers await first sight of the newborn at delivery, fatigue and commotion sometimes diminish preparedness for the unexpected. If unrecognized, these factors can impede the OB team's capacity to make rapid decisions and perform technical maneuvers with the precision necessary to prevent injury to mother and baby."

The report notes that the more severe injuries result from shoulder dystocia. Inexperience, especially with assistive devices such as forceps, vacuum, and dystocia maneuvers, often is identified as the primary reason for alleging negligence in the delivery process. Because complications that require assistive devices and techniques during a vaginal delivery might be infrequent for individual providers, inadequate experience and training can increase the risk of such interventions.

Drills and simulations can significantly reduce risk. Units that employ drills or simulation-based training focused on the decision to continue or alter the labor plan might encounter fewer unrecoverable situations and mitigate the dangers of fixation and indecision frequently present in delivery-related claims, Ruoff says. "Risk managers should look at the data in this report and ask if any of this resonates with them, whether some of the issues highlighted here can be found in their own organizations," she says. "Then we advise looking at whether you have enough data to do this kind of analysis of your own experience. Studying your aggregate claims data can reveal the issues particular to your organization and how they rank in prevalence with your OB claims, which may not be exactly the same as in another health system. Then you can investigate whether those problems still exist and how to remediate them."

That approach was the one taken by Marilyn Owens, ARM, CPHRM, Director, Risk Management for Cassatt RRG Holding Company, Berwyn, PA, a captive insurer of numerous hospitals in Pennsylvania. Owens compared her company's data with that of Crico Strategies, looking for indications that Cassatt might be weaker or stronger in certain areas related to OB cases. "Cassatt is quite comparable in many of the areas, and we're finding that we all seem to have difficulties in the same areas," Owens says. "Communication is really where hospitals need to focus. So many adverse events include communication as a contributing factor, so we are focusing on improving communication and teamwork."

To that end, Cassatt has provided training and simulation equipment to its member hospitals so clinicians can practice emergency drills for shoulder dystocia, maternal hemorrhaging, and other OB emergencies.

"The practicing helps them be able to communicate well and function well if an emergency presents itself," Owens says. "Communication and teamwork is where the support should be."


Marilyn Owens, ARM, CPHRM, Director, Risk Management for Cassatt RRG Holding Company, Berwyn, PA

Gretchen Ruoff, MPH, CPHRM, Program Director of Patient Safety Services, Crico Strategies, Cambridge, MA. Telephone: (617) 679-1312. E-mail: gruoff@rmfharvard.edu.