Risk Management:
Obstetrics - Risk Management Considerations
by Phyllis DeCola, Manager of Healthcare Risk Services, Princeton Insurance
Printable Version of this Article
The personal, professional and dollar cost of perinatal injury remains high as families faced with the financial burden of long term care for an injured child or mother, the perception that something wrong occurred and information has been withheld, a desire to prevent an accident from recurring…or simply a wish to “get even” often lead people down the path of litigation. Our statistics indicate that the average cost of indemnity paid on obstetrical claims over the past five years is more than double that of the average indemnity paid on all non-obstetrical claims combined.
An unexpected outcome does not always mean that the quality of care was compromised and a bad outcome doesn’t necessarily signify malpractice; however, negligence does occur… often the result of oversight, accident, or poor judgment due to lack of training or skill, miscommunication, or failure to act.
Non-medical causes of injury, such as damaged doctor-patient relationships, and erroneous or incomplete documentation as well as other preventable causes of physical and emotional injuries are often the catalysts for malpractice litigation. [i]
COMMUNICATION
One prevalent trend in virtually all malpractice suits is that a series of events usually occur…the most common stemming from a breakdown in communication, either between the practitioner and patient or between care givers. In fact, the generation of lawsuits – in the presence of an adverse outcome – is more often than not, precipitated by poor communication.[ii]
Communicating With Patients
Medical literature reports four types of communication problems cited in a majority of plaintiff depositions: deserting the patient, devaluing patients' views, delivering information poorly and failing to understand patients' perspectives. In a nutshell, healthcare practitioners must listen and talk to patients in a positive manner.
Communication experts stress the skills of engagement, empathy, education and enlistment to improve patient outcomes and patient compliance and to decrease the likelihood of malpractice suits.
Medicine has its own language, and healthcare practitioners must adapt their words to the patient’s level with appropriate questions and explanations. It is important to be cognizant of the cultural diversity that exists among your patient population. Consider gender, racial, and limited English proficiency (LEP) as well as whether patients are deaf or hard of hearing, being certain to make special accommodations for interpreters, when indicated.
Communicating With Other Practitioners
Many lawsuits in obstetrics stem from allegations of failure to notify or delay in notification of the physician. Some important elements for establishing good intraprofessional communication practices include a readily available list of all practitioners and those with whom they rotate calls; call schedules of all practitioners; telephone numbers and an established method of reaching the physician immediately, which eliminates triage through office personnel in order to reach the physician directly.
When hospital nurses and other staff call physicians, they should have accurate and timely information readily available for the practitioner. They should state immediately the reason for the call, and whether the practitioner is needed.
Of particular importance is a method to evaluate and promptly resolve problems with communication between hospital staff, physicians, and other practitioners. Chain of Command policies should also be established and followed, in which all staff, including physicians and residents, have a mechanism to immediately communicate upward, so that any concerns regarding patient care can be addressed.
Treat every member of the staff with professional courtesy and respect and deal with disagreements with other care providers outside of the medical record and earshot of patients.
Telephone Communications
Telephone conversations may be critical in a malpractice action. All prenatal telephone conversations with the patient, including those that take place outside the office setting should be documented in the prenatal record.
Be mindful of common pitfalls associated with telephone triaging including failure to accurately access maternal-fetal status, failure to advise the patient to seek evaluation and treatment, failure to correctly communicate maternal-fetal status to the primary health care provider, and failure of the physician/nurse-midwife to come to the hospital to see the woman when requested to do so by the nurse.
When Something Goes Wrong
When something does go wrong, the impulse to deny a problem and avoid the family can be strong. Patients often file malpractice suits against physicians because they feel that information was deliberately withheld, or the physician refused to apologize for what happened or they do not believe that the facility will prevent the problem from happening to another patient.
Always keep in mind, when talking to patients, what you would want a physician to tell you if something went wrong with you or your child's treatment. In order to decide on the best strategy, in these difficult cases, it is strongly suggested that physicians discuss the issue with a risk manager and medical leader before talking to the patient.
[i] Karp, D., The Misdirected Search for Malpractice Solutions, DCBA Brief (Journal of the DuPage County Bar Association – Online)
[ii] Virshup, B., Oppenberg, A., Coleman, M. Strategic Risk Management: Reducing Malpractice Claims Through More Effective Patient-Doctor Communication, American Journal of Medical Quality, Jul/Aug 1999
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