Top Median Malpractice Payments
Opioid Safety, Respiratory Compromise

3 Lessons for Preventing Death and Brain Damage in Newborns and Their Mothers

Can death and brain damage in newborns and their delivering mothers be prevented?

This is the question Michael Wong, JD (Founder and Executive Director, Physician-Patient Alliance for Health & Safety) asked at the recent conference 15th Annual Advanced Forum on Obstetric Malpractice Claims.Speaking on the panel discussion with Mr. Wong were:

  • Bruce Patsner, MD (Vice Chair, Quality, INOVA)
  • Angela W. Russell (Partner, Wilson Elser Moskowitz Edelman & Dicker LLP)
  • Jeffrey Segal, MD, JD (Founder and CEO, Medical Justice Services, Inc.)

According to an analysis of closed claims cases of the American Society of Anesthesiologists conducted by Joanna M. Davies, F.R.C.A. and her colleagues, Liability Associated with Obstetric Anesthesia: A Closed Claims Analysis,death and brain damage in newborns and their delivering mothers occurred in 51% the claims:

Top Liabilities in Obstetric Anesthesia

Top Liabilities in Obstetric Anesthesia

This analysis by Davies et al. also showed that the malpractice payments due to death or brain damage to either the newborn or the delivering mother outweighed payments for nerve or minor injuries to the mother:

Top Median Malpractice Payments

Top Median Malpractice Payments

So, can death and brain damage in newborns and their delivering mothers be prevented?

An analysis of closed claims data of the American Association of Nurse Anesthetists conducted by Karen Crawford, CRNA, PhD,The AANA Closed Malpractice Claims Study: Obstetric Anesthesiaprovides some answers.

This analysis of AANA closed claims data recommended three areas for improvement, which may have prevented these malpractice claims:

  • Have the right equipment present and make sure caregivers know how to use it.

In answering a question about whether the choice of venue played a role in the recent death of Joan Rivers, Kenneth P. Rothfield, M.D., M.B.A., Chairman, Department of Anesthesiology, Saint Agnes Hospital (who is on the Board of Advisors of PPAHS) commented: I dont think its the venue thats the most important thing. ASCs traditionally have done simpler procedures in healthy patients,while hospitals have routinely dealt with a broader and sicker mix of people. Hospitals, he said, are more likely to be fully equipped and to have staff members with greater experience handling emergencies. Unless you have drilled for it, and trained for it, it can be hard to pull off.

Have the right equipment present and make sure caregivers know how to use it #ptsafety Click To Tweet
  • Monitor patients with accepted standards of practice.

ECRI Institute says that inadequate monitoring for respiratory depression in patients receiving opioids poses the greatest risk to patients and assigned it a risk map of 80. In an interview with PPAHS, ECRIs Patient Safety Analyst, Stephanie Uses, PharmD, MJ, JD discusses why inadequate monitoring poses a significant patient safety risk. For this interview on YouTube, please click here.

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  • Accurately analyze the information provided by monitors and adjust the anesthetic care plan accordingly.

In a recent survey of nurses, the ability to accurately and efficiently assess patients for signs of respiratory compromise was identified as a key area for improvement.

Accurately analyze information provided by #monitors & adjust anesthetic care plan accordingly #ptsafety Click To Tweet

For a pdf of Mr. Wongs presentation, please click here.

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