Perinatal harm remains a significant exposure for hospitals. At CNA, our extensive claim data allows us to develop proprietary insights into the hospital market to better help hospitals address these vulnerable exposures. Consider the following findings from the CNA Hospital Professional Liability Claim Report 2015 regarding perinatal risks:
- Perinatal claims resulted in the report’s highest average total paid — $415,479 — than any other clinical service in the report.
- Of the hospital malpractice claims with a $1 million indemnity payment, 30 percent related to perinatal care.
- Of the 48 perinatal closed claims included in the report, 58.4 percent involved permanent injury, while one-third resulted in death.
- Maternal stays with pregnancy- and delivery-related complications had an overall cost of $17.4 billion, comprising nearly 5 percent of overall hospital costs in the U.S.1
Building upon the report findings, our September 2016 edition of Vantage Point® explores CNA obstetric-related claims data, revealing critical gaps in perinatal safety preparedness, which I outline below. These gaps are included in the broad categories of failure to intervene and common process failures.
Failure to intervene is cited in 70.8 percent of the 48 perinatal claims reviewed in the report. Within this category, mismanagement of labor was the highest allegation, accounting for 33.3 percent of the claims. However, mismanagement of labor ranked fourth in terms of severity, averaging $441,833 in total paid (i.e., legal expenses and indemnity). Also within this category, delay in treatment of a neonate represented 2.1 percent of the claims. While relatively rare, delay in treatment reflected the highest total paid, averaging $1,015,416. Other noteworthy allegations include: delay in delivery of fetus (10.3 percent of the claims); improper/untimely management of obstetrical patient (8.3 percent); failure to timely report complication of pregnancy/labor (4.2 percent); treatment/care — other (4.2 percent); failure to maintain infection control (4.2 percent); failure to invoke chain of command (2.1 percent); and delay in managing change in maternal condition (2.1 percent).
Common Process Failures
Many of the closed claims involved serious, lifelong consequences to both mothers and infants. Despite the severity of these complications, there is a troubling recurrence of various perinatal safety lapses, including the following:
- Failure to standardize practice guidelines for high-frequency clinical interventions, such as administrating labor-inducing agents
- Noncompliance with electronic fetal monitoring (EFM) certification, which promotes enterprise-wide standardization of interpretation and communication of fetal status
- Absence of a safe Cesarean delivery program, with safeguards such as surgical instrument counts
- Lack of safety checklists for high-risk clinical situations
- Insufficient training and simulation drills for high-risk events
- Failure to enforce an escalation algorithm for non-code changes in patient conditions
- Inadequate or poor clinical documentation practices
By understanding the common allegations and inherent risks in safety processes, your hospital can begin to develop its perinatal safety program (PSP).
Closing the Safety Gaps
PSPs play a major role in minimizing risks to both mothers and infants. Moreover, hospital leadership can help to reduce lawsuits emanating from maternal complications with an effective PSP. PSPs are also advantageous from an accountable care organization (ACO) perspective. They offer a sound approach to managing the health of a vulnerable, at-risk patient population, ultimately making hospitals more attractive partners for prospective ACOs.
Enhancing perinatal safety requires a combination of technical initiatives and procedural measures. Implementation of the following strategies should be considered:
- Utilize electronic health record systems to reinforce compliance with obstetrical practice bundles (evidence-based protocols designed to improve care processes and patient outcomes).
- Implement an escalation policy (i.e., chain of command) whenever patient safety is jeopardized in order to ensure timely, appropriate communication among nursing staff and medical providers. Require simulated crisis training for all levels of obstetrical-neonatal staff.
- Consider establishing a perinatal committee that oversees all aspects of perinatal services. Standardized protocols that reflect national, professional standards of care are an essential component of this process. For example, obstetric and perinatal physicians, midwives and nurses should use a standard terminology to improve communication.
To obtain detailed data and charts, suggested practice bundles, additional strategies and sample documentations, including a self-assessment tool to help get you started in addressing your hospital’s PSP today, access the comprehensive edition of Vantage Point.
1 Institute for Healthcare Improvement 2015.