Increasing the Reliable Capture of Risks
Obstetrics Checklist–University of California Davis
Lack of reporting to Risk Management following Obstetrics-related adverse events.
The overwhelming majority of the 1,800 births that occur in our hospital each year go unnoticed by those of us in risk management and loss prevention. Of course, we are delighted for those families, and proud of our Labor & Delivery team, but our job is to investigate the less-than-perfect outcomes. For both health care improvement and fiscal responsibility, we need to understand if there is something about adverse obstetrical events that needs our attention—that can be modified to prevent recurrence. Anecdotal accounts may be compelling, but they can also mislead us to focus on a one-off problem rather than systemic issues that put a greater number of patients at risk. To accomplish that, we need reliable reporting and credible data.
Like any academic medical center, we have tons of data to tap into for our quality and safety program. But UCD also has access to the unique Candello database of deeply-coded medical professional liability (MPL) cases from all over the United States. Thus, we not only capture our own (relatively few) suboptimal outcomes, we also can compare our experience and risk profile to our peers’ risk profiles. That capture and analysis is guided by our obstetrical incident reporting. By digging down to the specific components of suboptimal outcomes—or near misses—we gain a more precise understanding of where to focus safety interventions.
The Candello data directed us to create a checklist of adverse event factors that we need to analyze. Before that was practical, however, our Labor & Delivery teams needed help to systematically capture and share potential MPL claims with our third-party case administrator. To that end, we married our checklist with our incident debrief forms for specific adverse outcomes (e.g., maternal hemorrhage, shoulder dystocia, eclampsia, low Apgars). Of no surprise to those who have studied patient safety risk, these debriefs often highlight breakdowns in provider-to-provider communication. That has become the keystone of our safety improvement program and informs our planning for (anticipated) complex deliveries so that the L&D team is not caught unaware. As we developed shared algorithms for obstetric emergencies, we placed copies in the physician workroom, nurses’ station, and patient rooms.
Candello Data Provides Valuable Insights on Obstetrical Risks
(Samples: Candello Database; Not UC Davis-specific)
When our Chief of Obstetrics presented our research and action plan data to our quality forum, it was the first time we had shared Candello data with them. As they saw the relationship between a risk common to obstetrical care providers everywhere and our local experience, they clearly understood the need to support our efforts to improve communication among providers prior to, during, and after labor and delivery. One result is that we now have in situ simulations as well as programs in our simulation center.