Decreasing intrapartum malpractice: Targeting the most injurious neonatal adverse events

Abstract

Medical malpractice expenditures are mainly due to the occurrence of preventable harm with some of the highest liability rates in obstetrics. Establishing delivery system models which decrease preventable harm and malpractice risk have had varied results over the last decade. We conducted a case study of a risk reduction labor and delivery model at 5 demonstration sites. The model included standardized protocols for the most injurious events, training teams in labor and delivery emergencies, rapid reporting with cause analysis for all unplanned events, and disclosing unexpected occurrences to patients using coordinated communication and documentation. Each of the model's components required buy in from the hospital's clinical and administrative leadership, and it also required collaboration, training, and continual feedback to labor and delivery nurses, doctors, midwives, and risk managers. The case study examined the key elements in the development of the model based on interviews of all team members and document review. We also completed data analysis pre and post implementation of the new model to assess the impact on event reporting and high liability occurrence rates. After 27 months post implementation, reporting of unintended events increased significantly (43 vs 84 per 1000 births, p < .01) while high-risk malpractice events decreased significantly (14 vs 7 per 1000 births, p < .01). This decrease enabled money allotted for malpractice claims to be reallocated for the implementation of the new model at 42 additional labor and delivery sites. Due to these results, this multilevel integrated model showed promise.

Sustaining and spreading quality improvement: Decreasing intrapartum malpractice risk

“…34 In 2015, the Journal of Healthcare Risk Management published the results of this study in an article titled "Decreasing Intrapartum Malpractice: Targeting the Most Injurious Neonatal Adverse Events." 28 The study revealed that 27 months after implementation, high malpractice risk events had decreased significantly, enabling money allotted for malpractice claims to be reallocated to the spread of the model to 32 additional sites.…”

“…Beginning in 2011, the health system's Perinatal Safety Committee implemented, evaluated, and published the results of a multilevel integrated practice and coordinated communication model designed to decrease the occurrence of two labor and delivery events, selected because they had the highest rates of long-term neonatal injury and malpractice liability. 28 The first, a shoulder dystocia emergency, occurs when gentle downward traction on the fetal head fails to effect delivery of the infant's shoulders, requiring immediate and sometimes substantial manipulation of the fetus and repositioning of the mother to enable the shoulders to pass below the symphysis pubis. 29 Complications resulting from shoulder dystocia can affect both the mother and infant, and can include long-term paralysis of the infant's shoulder, arm, and/or hand.…”

“…This process included developing an internal reporting system, establishing organized processes for coordinating disclosures, providing training for labor and delivery teams, and creating standardized investigation and disclosure guidelines. 28 The new model was implemented at 5 beta sites: This study examines the sustainability of the model at the 5 beta sites 39 months after the original study period, as well as the results of spreading the model to the 32 additional sites. Spreading the model to the additional sites was accomplished over several years, with informal diffusion beginning in 2011 and formal implementation initiated in 2013.…”

“…The second area of focus was the clinical team's response to abnormal or indeterminate fetal heart rate tracings (formerly termed nonreassuring fetal status or fetal distress ) detected through electronic fetal monitoring, ineffective use of which is the root cause of approximately one third of all perinatal deaths and injury . In 2015, the Journal of Healthcare Risk Management published the results of this study in an article titled “Decreasing Intrapartum Malpractice: Targeting the Most Injurious Neonatal Adverse Events.” The study revealed that 27 months after implementation, high malpractice risk events had decreased significantly, enabling money allotted for malpractice claims to be reallocated to the spread of the model to 32 additional sites.…”

“…Resolve Early.” (CORE ® ), was implemented. This process included developing an internal reporting system, establishing organized processes for coordinating disclosures, providing training for labor and delivery teams, and creating standardized investigation and disclosure guidelines …”