Edmund Funai, M.D. from Yale-New Haven Hospital presented at the annual meeting of the Society for Maternal-Fetal Medicine results of implementation of a multifactorial strategy to reduce obstetrical errors (1). The program he and his colleagues implemented successfully reduced errors by 50% over a two and one-half year period and helped to significantly lower the hospital’s malpractice premiums.
The intervention used several well-established patient safety tools and techniques, such as communication training and standardization (in this case standardization of interpretation of fetal monitoring) and introduced a new patient safety nursing position. They also developed a multidisciplinary committee to oversee the patient safety activities.
It’s well-known that communication breakdowns have been consistently seen as root causes in 60-70% of all sentinel events reported to Joint Commission. The communication training they utilized involved mandatory crew resource management (CRM) training.
The Yale press release includes a link to a 13-minute discussion with Dr. Funai in iTunes format. He discusses the fact that communications breakdowns underlie the vast majority of adverse events. In particular, he points out the increase in handoffs resulting from new residency workhour restrictions and their potential role in communication breakdowns. He stresses the importance of empowering any and all members of the team to speak up when they see something is possibly wrong. The added patient safety nurse improved continuity of care considerably, served as a patient safety resource, and helped review adverse events. Their implementation also included standardization of some interventions, such as administration of oxytocin.
We’ll echo the value of addition of a nurse clinician to the team. In the mid-1990’s we developed a nurse case manager program at the Erie County Medical Center at a time when residency workhour restrictions were first being instituted in New York state. We utilized experienced, respected nurse clinicians who understood systems of care. We found that the nurse case manager improved continuity of care tremendously, not only on a day-to-day basis, but also when teaching services would “rotate” on a monthly basis. This program was largely responsible for a substantial improvement in mortality rates, reduction in length of stay, and improvement in patient and family satisfaction. Sometimes adding a valuable resource can result in an overall net savings of human and financial resources. This is especially so in teaching hospitals.
A second presentation by staff from Lehigh Valley Hospital (2) at the same annual meeting of the Society for Maternal-Fetal Medicine also demonstrated a drop in errors after implementation of crew resource management.
These articles are of interest since a previous randomized controlled trial of teamwork training by Nielsen et al (3) failed to demonstrate measurable improvements in labor and delivery outcomes. It may be that the time period for translation of the improved team communication to hard outcome results is longer than in this study. However, the Nielsen study is a good reminder that we should not simply accept concepts and ideas that sound rational but we need to validate their effects on hard outcomes.
Simulation is another tool that has been gaining more widespread acceptance in the patient safety community. Maslovitz et al (4) developed a simulation-based curriculum for ob/gyn residents and midwives and were able to identify multiple recurrent mistakes in the management of several emergency scenarios. For example, in one scenario they found that late transfer to the operating room and delayed administration of blood products seemed to occur because almost all trainees inaccurately estimated the blood loss by a mean factor of 50%. The authors have used this information to begin testing solutions to the problems identified. They also demonstrated improvement in management when some of the trainees later repeated the simulation scenarios.
An excellent paper by Foster et al (5) used a trigger tool to study adverse events on an obstetric service. (See our October 30, 2007 Patient Safety Tip of the Week “Using IHI's Global Trigger Tool” for a description of the use of trigger tools.) They confirmed that severe adverse events are rare in obstetrics and their overall incidence of adverse events was only 2%. However, they identified important quality problems in 5% of the cases. Importantly, most of these were preventable systems problems that subsequently led to search for possible solutions. Based on the types of problems they identified, they concluded that interventions most likely to have a positive impact on patient safety would be those that focus on team work, communication, and work flow.
These are all good examples of how the ob/gyn community is beginning to incorporate patient safety into both their training programs and actual practice.
(1) Press release Yale University. New Strategy Helps Reduce Errors in Obstetrical Care. February 2, 2008 http://www.yale.edu/opa/newsr/08-02-02-01.all.html
(2) Beil L. Medscape Medical News. Two Studies Describe Approaches Shown to Reduce Obstetrical Errors. February 4, 2008 http://www.medscape.com/viewarticle/569668
(3) Nielsen PE, Goldman MB, Mann S, Shapiro DE, Marcus RG, Pratt SD, Greenberg P, McNamee P, Salisbury M, Birnbach DJ, Gluck PA, Pearlman MD, King H, Tornberg DN, Sachs BP. Effects of Teamwork Training on Adverse Outcomes and Process of Care in Labor and Delivery: A Randomized Controlled Trial. Obstetrics & Gynecology 2007; 109(1): 48-55
(4) Maslovitz S, Barkai G, Lessing, JB, Ziv A, Many A. Recurrent Obstetric Management Mistakes Identified by Simulation. Obstetrics & Gynecology 2007; 109(6): 1295-1300
(5) Forster AJ, Fung I, Caughey S, Oppenheimer L, Beach C, Shojania KG; van Walraven C. Adverse Events Detected by Clinical Surveillance on an Obstetric Service. Obstetrics & Gynecology 2006; 108(5): 1073-1083