Physicians often encounter a “black box” in terms of where to focus their patient safety efforts. Obstetricians care for two patients – mothers and babies – simultaneously, which presents significant challenges. Safe obstetric care requires a multidisciplinary team with good communication skills. At the same time, gynecologic procedures are becoming more complex, and caring for a patient with complications can be quite challenging.
Breakdowns in communication often lead to adverse outcomes. Using closed obstetric malpractice claims allows practicing clinicians to understand where to focus their improvement efforts. The Doctors Company recently performed an analysis of 944 closed obstetric-gynecologic claims using a lexicon that is common to many other insurers. The study found that across patient claims, communication-related issues were common to nearly all allegations of ob.gyn.-related patient injury. The claims data revealed that key communication failures were in two major areas: communications with our patients and communication among team members, including the physician.
Dr. Susan Mann
Physician-patient communication
Consider this example: Dr. S. is caring for a patient at term. At delivery, the infant has no heart rate and no respiratory effort and undergoes a full code and has APGAR scores of 0,0, and 3. While the indication for cesarean delivery was a nonreassuring fetal status, this was a surprising outcome. The team sent the placenta to the pathologist and there was an unusual finding of an amniotic web and the umbilical cord showed venous necrosis. A family meeting was held with the pathologist to explain the findings and the relationship to the baby’s need for support. While the presentation of the information did not change the outcome for the infant, it helped the patients and family to understand how the neonatal outcome occurred and that it was remote from delivery.
Common factors contributing to communication issues between physicians and patients/families include inadequate consent for treatment options; poor patient rapport, including unsympathetic responses to the patient; and language barriers, according to The Doctors Company’s clinical guide to improving patient safety and managing risks.
A fundamental step to address these factors is early education for patients and families about the risks and benefits of treatment, which is essential to reinforce understanding of potential interventions. Informed consent is a critical element of early education, but is often done in a rush, in a busy office setting – making it a critical risk factor. Having the informed consent conversation when the decision is made to go to surgery is important, but encouraging patients to bring forward questions and allowing their loved ones to have a clear understanding of their recovery process is also very helpful. When an unexpected complication occurs, having had a complete discussion about risks can help to mitigate an otherwise difficult situation.
We are often busy and stressed when complications arise, and the reflex is to withdraw from the patient who has suffered the complication. Demonstrating genuine empathy toward these patients allows the human side of physician-patient interaction to become apparent, which not only can reduce the patient’s and the family’s anger and frustration at a complicated situation but also can reduce the legal risk for the physician.
Provider communication
Consider another example: Ms. G is a 36-year old G1P0 who presented to the labor and delivery unit with severe preeclampsia. Failure to communicate a clear plan of action for management of her severe hypertension to all team members led to undertreated hypertension, a major stroke, and maternal death.
Both obstetrics and gynecology are specialties that require multidisciplinary teams, including nursing, anesthesia colleagues, consultants, and if at a teaching hospital, residents and medical and nursing students. Teamwork training initiatives can encourage providers to move out of their individual silos, practice more collaboratively, and share information across disciplines in a succinct and timely fashion. Understanding patients’ plans of care and competing resource demands allows a team to manage risk together.
Having a shared mental model and situation awareness across the team also creates a safety net for patients. This type of shared information is something highly reliable teams train on and communicate across disciplines, as this is not often taught in medical or nursing schools. Having clear roles and responsibilities allows professionals to create and understand expectations, especially around sharing safety concerns.
In situ simulations of high-risk situations both in labor and delivery and in the operating rooms are wonderful and instructive ways to practice teamwork behaviors. This type of exercise allows staff to practice skills together while discovering system failures in a nonthreatening environment. Later debriefing these activities allows staff to reflect on their own behavior and learn from one another, as well as to identify systems that need additional work.
Addressing patient safety risks effectively means focusing our energy and efforts toward underlying vulnerabilities that place patients at risk and increase liability for doctors. Sharing the results of lessons learned, through the evaluation of malpractice claims, helps to identify areas of vulnerabilities. Working to improve our communication with patients, families, and other providers, we can systematically lower risk to the patient and lower the risk of litigation to physicians.
Dr. Mann, an ob.gyn., is an assistant professor, part-time, at Harvard Medical School in Boston, and is a national consultant in patient safety and quality improvement in the field of obstetrics. She is a member of the Obstetrics Advisory Board of The Doctors Company. She is also a consultant at Harvard’s Risk Management Foundation, Dana-Farber Cancer Institute, and many institutions across the United States.