Our objective was to describe a comprehensive obstetric patient safety program and its effect on reducing compensation payments and sentinel adverse events. From 2003 to 2009, we implemented a comprehensive obstetric patient safety program at our institution with multiple integrated components. To evaluate its effect on compensation payments and sentinel events, we gathered data on compensation payments and sentinel events retrospectively from 2003, when the program was initiated, through 2009. Average yearly compensation payments decreased from $27,591,610 between 2003-2006 to $2,550,136 between 2007-2009, sentinel events decreased from 5 in 2000 to none in 2008 and 2009. Instituting a comprehensive obstetric patient safety program decreased compensation payments and sentinel events resulting in immediate and significant savings.
Improving patient safety has become an important goal for hospitals, physicians, patients, and insurers. Implementing patient safety measures and promoting an organized culture of safety, including the use of highly specialized protocols, has been shown to decrease adverse outcomes; however, it is less clear whether decreasing adverse outcomes also reduces compensation payments and sentinel events.
Our objective is to describe comprehensive changes to our obstetric patient safety program and to report their impact on actual spent compensation payments (sum of indemnity and expenses paid) and sentinel events.
Materials and Methods
New York Presbyterian Hospital-Weill Cornell Medical Center is a tertiary academic referral center with a level 3 neonatal intensive care unit and serves as a New York State regional perinatal center. The labor and delivery unit performs about 5200 deliveries per year of which voluntary attending physicians manage approximately 25%, and 75% are managed by full-time faculty.
The New York Weill Cornell Investigation Research Board approved this report as exempt research.
Patient safety program
In 2002, we began to implement in a step-wise fashion a comprehensive and ongoing patient safety program. The date of implementation is included for each step.
Consultant Review (2002)
In 2002, as part of an obstetric initiative by our insurance carrier (MCIC Vermont, Inc, Burlington, VT), 2 independent consultants reviewed our department and assessed our institution’s obstetric service. This review resulted in specific recommendations and provided a general outline for making changes and improvements in patient safety. Building on these findings, we implemented a comprehensive obstetric patient safety program.
Labor and delivery team training (2003)
Poor communication is among the most cited reasons for malpractice suits, whereas improved nurse-physician communication can make labor and delivery safer. Consequently, the Institute of Medicine recommended interdisciplinary team training programs for providers to incorporate proven methods of team training as a way to improve efforts and to empower every team member to speak up and intervene if an unsafe situation may be occurring. Crew Resource Management (CRM) can potentially decrease medical malpractice litigation, mostly by improving communication, but studies have been less clear about its effect on adverse outcomes.
In 2003, several of our labor and delivery staff members including nurses, obstetricians, and anesthesiologists attended a “train the trainer” team-training course. Subsequently, all staff working on labor and delivery including clerical staff, nurses, attending obstetricians, neonatologists, anesthesiologists, and residents successfully attended a 4-hour team training session and team principles were introduced on labor and delivery. Since then, all new staff has been required to attend labor and delivery team training sessions. The CRM program is performed regularly every 2-3 months. New staff, including nurses, attending, residents, and clerical staff, are scheduled to undertake CRM at the next available time. Attending physicians are instructed that credentialing/privileges will not be granted or renewed if CRM is not completed and nursing staff and residents are informed that they must take the CRM program within a year after employment begins.
Electronic medical record charting (2003)
Good medical record charting can help defend professional liability cases and may persuade potential plaintiffs to forego filing a suit and electronic health records on labor and delivery are less likely to miss key clinical information. To facilitate communication and to improve patient safety, we were among the first departments in our institution to require electronic medical record charting with Eclipsys XA (Eclipsys Corporation, Boca Raton, FL) for all patients on labor and delivery. OB Tracevue (Phillips, Andover, MA) is used for electronic fetal monitoring (EFM). All documentation occurs in these electronic formats. Paper documentation is not allowed, except when the electronic format is temporarily incapacitated.
Chain of communication for labor and delivery (2003)
Communication on labor and delivery is crucial to ensure patient safety and to provide the best care for patients and prevent errors, but there are times when physician’s orders and actions need to be questioned. We believed that the most effective way for staff on the labor and delivery unit to voice their concerns is to establish and promote chain-of-communication policies. In 2004, a new chief of labor and delivery was appointed and a clear chain of communication was established and supported by the departmental chairman ( Figure 1 ). The chain of communication includes involvement of all staff beginning at the nurse and junior resident level, then up to the chief resident, the inhouse attending, the maternal-fetal medicine specialist on call, and finally the director of labor and delivery and the chairman of the department. All staff are being empowered to use the chain of communication frequently and around the clock to ensure a quick resolution to unresolved and urgent issues.
Dedicated gynecology attending on call (2004)
A gynecology attending on call schedule was established separately from the obstetric coverage. Before this change, the labor and delivery attending covered both the obstetric and gynecology services and there had been occasions when there were concurrent emergency gynecologic and obstetric cases. This situation prevented the attending from sufficiently covering both services. The added gynecology coverage allowed the labor and delivery attending to cover the labor floor exclusively.
Limitation of misoprostol to induction of labor or cervical ripening for a nonviable fetus (2004)
Misoprostol is not US Federal Drug Administration (FDA) approved for use during labor. There is evidence that misoprostol is not effective, and its use is associated with an increase in hyperstimulation/tachysystole.
Misoprostol has never been used at the medical center for a live fetus. After the warning from the Searle company discouraging its use in the year 2000, there was no incentive to begin using this medication at our institution, and our concern about potential adverse outcomes led us to conclude that misoprostol use should be limited to induction of labor and cervical ripening only in the nonviable fetus.
Standardized oxytocin labor induction and stimulation protocol (2005)
A standardized protocol enables the staff to become facile in handling the myriad of problems that occur on any busy unit, quickly and efficiently. In 2005, we implemented a standardized low-dose oxytocin labor induction and stimulation policy ( Table 1 ) and a standardized order template was designed in the hospital’s electronic ordering system (Eclipsys, Atlanta, GA). No other method of using intrapartum oxytocin was permitted. Highlights of this protocol included a premixed oxytocin solution, a required written attending order and note before starting the oxytocin infusion, a standardized starting dosage and increases, and a “smart pump” (a pump that comes with an error reduction system and drug library capabilities). The protocol paid special attention to tachysystole and fetal heart rate concerns. If there was tachysytole, or there were concerns about the fetal heart rate, the oxytocin infusion had to be decreased or stopped.
| Item | Protocol |
|---|---|
| a. | Only a premixed oxytocin solution is used |
| b. | The oxytocin infusion is limited to intravenous route via an infusion pump |
| c. | A buretrol infusion is used with a “smart pump” (a pump that comes with error reduction system and drug library capabilities) |
| d. | The infusion is piggybacked into the port most proximal to patient |
| e. | A written attending order (electronic template) is required before the start of oxytocin |
| f. | Before the start of oxytocin an attending must document the plan of care including indication, fetal presentation and station, cervical status, estimated fetal weight, pelvic adequacy, and fetal heart rate assessment. |
| g. | An attending must be available on the same floor as labor and delivery floor at all times while the patient is on oxytocin |
| h. | Before initiation of oxytocin a reassuring fetal heart rate must be present for a minimum of 20 minutes |
| i. | The oxytocin concentration is a premixed solution of 30 U per 500 mL. No individual mixing of solutions is permitted onsite. |
| j. | The oxytocin infusion begins at 1 mU per minute. |
| k. | The infusion is increased by 1 mU per minute no more frequently than every 15 minutes |
| l. | An attending must evaluate, document, and determine the plan of care if the oxytocin dosage reaches 20 mU per minute |
| m. | The maximum oxytocin dosage cannot exceed 40 mU per minute |
| n. | If the oxytocin infusion was discontinued for 20 minutes or less, it may be restarted at a lower rate than before discontinuation. If it was stopped for greater than 20 minutes then it should be restarted at 1 mU per minute |
| o. | Only a nurse can titrate oxytocin. The nurse can stop or titrate the oxytocin infusion if indicated. The doctor must be notified of this. |
| p. | The oxytocin infusion must be stopped or titrated for any of the following: uterine hyperstimulation/tachysystole (contractions less than 2 minutes in frequency and/or lasting longer than 90 seconds and/or more than 5 contractions in any 10 minute period); elevated uterine resting tone; nonreassuring fetal heart rate tracing; presumed uterine rupture; water intoxication |
| q. | The attending physician must be notified of any hyperstimulation/tachystole, abnormal fetal heart rate changes and/or stoppage or down titration of oxytocin. |
| r. | Terbutaline may be given if stopping oxytocin does not lead to a normalization of fetal heart rate changes in the presence of hyperstimulation |
| s. | Oxytocin should be discontinued as soon as a cesarean delivery is planned |
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