Introduction
In the past decade there has been a dramatic increase in our understanding of the important contribution of medical errors as a cause of morbidity and mortality. National attention in the United States was brought to this issue in 1999 with the publication of the Institute of Medicine’s Report To err is human: building a safer health system [1]. This report summarized data that presented medical errors as the eighth leading cause of death in the US, being responsible for between 48,000 and 98,000 deaths per year – more deaths than are attributable each year to motor vehicle accidents, breast cancer or HIV infection. Similar reports have been published in many other Western countries before and since 1999 suggesting that this problem is not unique to the US healthcare system [2,3]. Nor does this problem appear unique to medical or surgical patients. A 4-year review of maternal mortality in North Carolina in the US found that 40% of deaths were potentially preventable by improvements in care [4]. The United Kingdom’s excellent Confidential Enquiry into Maternal and Child Health (CEMACH), which reviews all maternal deaths in the UK, identified some degree of substandard care in 64% of deaths directly attributable to a pregnancy complication and in 40% of those patients for whom pregnancy was considered to be at least a contributing factor in their death [5].
After a dramatic progressive drop in the maternal mortality rate over the first three-quarters of the past century in both the US and the UK, little progress has since been made in either country. In recent data from both the UK and US, medical illness, rather than obstetric causes, appears to be a key contributor in a manner that was not true in the past. In 1952, a little under half of the maternal mortality in the UK was attributable to medical causes while in the year 2000, this portion had risen to 81%. Delayed childbearing, advances in reproductive technologies, and better medical care of women with chronic medical illness have all likely contributed to an increase in the number of pregnant women with medical problems. However, the change in relative proportion of deaths due to obstetric versus medical causes may also suggest the possibility that the progress in obstetric and anesthetic care seen in the past century has not been matched by medical care during pregnancy.
For the majority of obstetric patients, medical care follows a similar successful course down a well-worn path. Since serious medical complications are relatively rare, obstetricians, internists, anesthesiologists, and nurses are unable to gain day-to-day clinical experience that helps promote excellence in the management of serious medical complications during pregnancy. The obstetric population is one that is often highly resilient to less than optimal care; however, the stakes remain very high for the patient and her partner, her infant, and caregivers. What can be done to minimize the risk to women with medical illness in pregnancy? Application of safety principles from other industries and areas of healthcare offers our present best hope of adequately addressing errors in the care of obstetric patients with medical disorders. These principles are listed in Box 50.1 and discussed below.
Box 50.1 Four principles for increasing the medical safety of pregnant women
- Promoting a safe culture
- Identifying those at risk
- Intervening early
- Preparing for emergencies
Increasing the medical safety of pregnant women
Safety culture
Of the four safety principles listed in Box 50.1, a “safety culture” is the least quantifiable but perhaps the most important. A culture of safety can be broadly defined as one that makes it more likely that the caregivers will do the right thing and less likely that they will do the wrong one. It has many contributing elements and factors, but four features listed in Box 50.2 are crucial and discussed below.
Standardizing care
Although many physicians pride themselves on the art of medicine and their unique and distinct approach to care, these variations in practice, although perhaps important to medical progress, come at a price to patient safety. Variations in practice over matters unlikely to affect clinical outcomes increase the likelihood of error by asking other providers, pharmacists, nurses, and midwives to “learn” a wide variety of practices, making it more likely that an error due to variance will occur. Safe hospital cultures are ones in which standardized guidelines and protocols of care are developed and disseminated and in which compliance with them is audited and promoted. Although the best justification for such protocols will be evidence based, standardization has merit from a safety perspective even in the absence of knowing the single best way to do something. In the best safety cultures, variation from accepted protocols is open to inquiry by and discussion with any member of the care team to ensure the variation is understood and carefully applied.
Promoting vigilance
In many cases of poor maternal outcome, early signs of maternal deterioration are missed, responded to inadequately and/or communicated poorly. There may even be a failure to obtain complete or accurate vital signs, or for abnormalities to be communicated to the patient’s provider. There may be a failure on the provider’s part to make a complete assessment of the patient and/or to clearly communicate a plan to the patient and nurse. Defining the vital signs that require the obstetrician be notified, and delineating what the expected response to such calls should be can help prevent unnecessary delays in assessment and treatment that can contribute to poor outcomes. Ensuring that providers who have made an assessment share their conclusions and plan with other members of the care team is critical to creating a shared mental model of the next steps for patient care.
Box 50.2 Elements of a safe culture
- Standardizing care according to accepted protocols
- Promoting vigilance
- Promoting transparency
- Promoting teamwork
Transparency
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