Reducing Obstetric Malpractice Claims Starts With Training, Communication, and Culture

Medical malpractice claims, usually related to death or major injury, represent 69.6% of inpatient claims and 63.7% of outpatient claims. To help reduce medical malpractice, here are 5 key steps to minimizing exposure to medical malpractice litigation and improving patient safety & health outcomes

By Michael Wong, JD (Founder and Executive Director, Physician-Patient Alliance for Health & Safety).

Can “perfect care” exist in the clinical setting? This is one of the questions that was asked at a recent conference that I spoke at with Bruce Pastner, MD, JD (Vice-Chair, Patient Safety & Quality, Inova Fairfax Women’s Hospital).

It’s a utopic vision for patient safety that we all strive for. But the unfortunate reality of healthcare today is that bad outcomes can happen; this is sadly true in practices regarded as higher-risk, such as obstetrics. Not all terrible events leading to death or major injury are predictable, preventable, or even treatable. What clinicians can do, however, is to focus on identifying the most preventable incidents and prepare for them.

In doing so, hospitals can ensure a greater standard of care for their patients and – in turn – reduce the level of medical malpractice claims that they experience. Medical malpractice claims, usually related to death or major injury, represent 69.6% of inpatient claims and 63.7% of outpatient claims. While standards of care at the hospital level have slowly increased over the years, resulting in reduced malpractice claims, there will always be room for improvement.

This improvement can be achieved through 5 key steps to minimizing exposure to medical malpractice litigation and improving patient safety & health outcomes:

  1. Observing Protocol
  2. Identifying High Risk Patients
  3. Ensuring Documentation is Complete
  4. Communication (including handoffs communication)
  5. Disclosure communication

People management is a critical element making improvements a reality. Patient safety starts with empowering clinicians to act in these scenarios with the right combination of training, staff communication, and hospital-wide culture of safety. Throughout this article aree examples of how this is implemented at Inova Fairfax Women’s Hospital’s Obstetrics department, though the principles can be applied in any clinical setting.

1. Train for Multiple Scenarios

Effective training falls under two key pillars:

  1. The development of and adherence to standardized protocols for a broad spectrum of scenarios and;
  2. Situational training focused on identifying and addressing high-risk patients.

Onboarding training alone is not sufficient to prepare staff to deal with real-world situations during stressful moments. Some of the steps that are being taken at Inova to ensure readiness are ongoing simulation training for specific high-risk scenarios, such as hemorrhagic events and operative obstetric complications (such as shoulder dystocia). This is coupled with mandatory annual certification courses, such as fetal heart rate monitoring, to keep crucial skills up-to-date for all staff.

2. Improve Hospital-Wide Communication

Communication errors, particularly during hand-offs, are critical contributing factors to many medical malpractice claims.

Sometimes this can be addressed as simply as ensuring that all documentation is completed as patients progress between different teams. If thoughtfully developed and adhered to, checklists can be effective documents to clearly communicate key information and proactively prevent many medical mistakes.

And in the case that adverse events do happen, well-kept documentation provides an avenue for both clinicians and patients to clearly understand why things went wrong. A study published in the Cleveland Clinic Journal of Medicine found that many patients who sought attorneys complained that they had never received a satisfactory explanation from the physician for why the adverse event occurred, compounding the original problem.

Fostering strong lines of communication does not end with checklists, however. At Inova, steps are being taken to reduce the total number of handoffs per patient – key times when communication breakdowns can occur. When a high-risk patient is admitted to the hospital, there is also an immediate notification of all of the key departments that could be involved: Pharmacy, Gyn-Oncology, Shock Trauma, and Interventional Radiology.

3. Foster a positive culture of safety

In an interview with Peggy Lange RT, Respiratory Therapy Department Director at St. Cloud Hospital in St. Cloud, MN, Ms. Lange refers to a state of readiness as acting as if in an “intensive care environment”. Shaping an institutional culture of safety capable of proactively addressing adverse events can be a daunting task, particularly with where to start. Quite simply, long-lasting cultural change starts from the top, with direction from the executive level to build a highly-reliably organization.

How this direction manifests itself is up to each hospital’s individual needs. At Inova, there is a dedicated Quality & Patient Safety Vice-Chair responsible to the Chairman & Board. This full-time role works with each department head to uphold the hospital’s standard of care. A key component of this is the immediate debrief of all sentinel events and major adverse events to ensure that they are not repeated.

Developing such protocols at this level is not the end. Ultimately, an effective culture of safety empowers clinicians to make effective decisions and feel comfortable escalating issues to superiors.

Implementing these people-focused approaches to improving patient safety have transformed Inova over the last 3 years. The hospital’s Leapfrog Hospital Safety grades rank at the top of the index for ‘training to improve safety’, ‘effective leadership to prevent errors’, and ‘staff work together to prevent errors’. Reducing adverse events is an ongoing process; at Inova, Mr. Patsner tells me they continue  to learn and improve everyday.

Implementing effective training modules, improving hospital-wide communication, and fostering a culture of safety is only possible if fostered by leaders in the hospital. A recent Joint Commission Sentinel Alert states this well:

Competent and thoughtful leaders contribute to improvements in safety and organizational culture. They understand that systemic flaws exist and each step in a care process has the potential for failure simply because humans make mistakes.

It’s also a reminder that the leadership needs to drive these changes and keep patients safe, and that leadership is not limited to the executive level. It requires a commitment from staff and, in particular, their leaders across the hospital to make this a reality.

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