Patient Safety in Obstetrics
Christian M. Pettker, MD
A 26 year-old G2 P1 arrives on a busy L&D in active labor at 2 a.m., but her prenatal chart has failed to accompany her and her primary physician is on vacation. The covering physician’s sign-out report failed to mention that her first delivery was complicated by a neonatal collar-bone fracture. Hours after admission, her delivery is complicated by a three-and-a-half-minute shoulder dystocia refractory to all initial interventions and ultimately resolved by extraction of the posterior arm.
A jet is taxiing down a busy runway in the Canary Islands. A senior Dutch KLM pilot is speaking to the overworked Spanish air traffic controller in English. The former misconstrues the latter’s order to stop for a command to go. While the aircraft’s navigator, whose English is better, understands the error, he is too intimidated and/or distracted to warn the pilot off. The plane collides with a landing 747 with great loss of life.
So what does the case of shoulder dystocia have to do with the jet collision? They were both potentially avoidable by better communication. The 1999 Institute of Medicine (IOM) report on medical errors in the U.S., To Err is Human: Building a Safer Health System, estimated that 44,000-98,000 patients die each year as a result of preventable faults and that more than 50% of all medical errors were at least partially attributable to communication errors. Moreover, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has determined that over two-thirds of serious and unexpected events may be traced back to communication failures.
To improve communication and enhance the culture of safety, Yale’s Obstetric service has embarked on a broad series of initiatives. Every member of the team, from those who help keep the unit clean to the most senior attendings, has had formal training in communication based upon the principles of Crew Resource Management (CRM) developed by the aviation industry. In our version of CRM, we have two teams on Labor & Delivery. The core team consists of the primary caregiver (obstetrician, resident, midwife, or all three) and the primary nurse. The core teams are backed up by our own version of a combined coordinating and contingency team. The Yale-On Call Attending (a 24/7 Maternal-Fetal Medicine hospitalist) and charge nurse serve to coordinate patient flow, triage patients in the queue for Cesarean deliveries, adjudicate competing claims for induction slots, and round with the core teams to ensure that all appropriate information is available and has been considered.
Beyond CRM, we have implemented a series of further safety enhancements, including:
1) the creation of the dedicated position of Patient Safety nurse to support performance improvement full-time, 2) protocol-based standardization of common procedures such as administration of oxytocin, 3) adoption of standardized terminology for interpretation of fetal heart rate monitoring, culminating in a national certification exam, 4) multidisciplinary oversight of performance by a department-based Patient Safety Committee, tracking and analyzing 14 individual outcomes (such as five-minute Apgar scores < 7, unexpected NICU admissions, and 3rd and 4th degree lacerations) for trend, and 5) simulation and drills for high risk/low frequency events such as shoulder dystocia and postpartum hemorrhage.
Over the course of about three years (and nearly 14,000 deliveries), these efforts have borne fruit. Though our adverse outcome rate is lower than that published by other units across the country, we have seen a significant incremental reduction in adverse events over time.
All of our physicians and nurses have attended CRM and passed national certification exams in electronic fetal monitoring. Staff perception of our teamwork and safety climates improved 50% and 100% respectively. Our data show that Yale Obstetrics is and feels safer! Further improvements currently underway include enhanced computerized notes and medication order-entry, more systematic handoffs and sign-outs, and an expansion of our simulations and drills. In all of these efforts, Yale has led the way in this field. Members of the Yale team have presented this strategy to other units across the country and in 2007 were given an Award of Research Excellence at the annual meeting of the Society for Maternal-Fetal Medicine for this work. Our example will not only benefit our own patients, but will also be used to transform patient safety in OB across the U.S. The culture of any Labor & Delivery unit is marked by greatly disparate experiences: long periods of waiting are punctuated by periods of stress and chaos, while the joy of new life is counterbalanced by rare tragedy.
Yale Obstetrics has worked to meet the expectations of families for a normal and safe birth outcome, while balancing the needs of being a high-risk pregnancy referral center. A comprehensive approach to patient safety can impact this unique culture, and can create a safer and more satisfying experience for patients and staff.
For more information contact: Christian.Pettker@yale.edu