Four Steps Can Reduce Hospital-Based Malpractice


SAN FRANCISCO — Abiding by four practice patterns might avoid nearly two-thirds of the costs of malpractice litigation for hospital-based obstetrics, Dr. Steven L. Clark said in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

A review of all 189 closed perinatal malpractice claims in one health care system between 2000 and 2005 found that 61% involved substandard care. These accounted for 79% of the approximately $168 million paid out during that period in court judgments or to settle cases out of court, reported Dr. Clark of the Hospital Corporation of America, Nashville, Tenn., and his associates.

Substandard care was defined as practice that was at odds with (or was judged by a treating physician or defense consultant to be at odds with) guidelines published by the American College of Obstetricians and Gynecologists.

Millions of dollars in litigation costs might have been avoided if these four practices had been followed:

▸ Practicing obstetrics in a facility with 24-hour in-house obstetric coverage. This might have eliminated 23% of cases (and 14% of total litigation costs) related to fetal monitoring for deliveries other than vaginal births after previous C-section (VBACs).

▸ Adhering to existing checklist-driven protocols for administering oxytocin, misoprostol, and magnesium sulfate. This might have avoided 45% of cases and 27% of total costs related to fetal monitoring in non-VBAC deliveries, as well as 16% of maternal injury cases (and 3% of total costs).

Following either of these first two practices might have avoided an additional 17% of other cases (and 10% of total costs) related to fetal monitoring.

▸ Taking a more conservative approach to VBAC by limiting VBAC to spontaneous labors progressing without augmentation and without repetitive moderate or severe variable decelerations.

▸ Using a comprehensive, standardized procedure note for complete and consistent documentation in cases of shoulder dystocia. This could have avoided 54% of fetal losses (and 4% of all litigation costs) associated with shoulder dystocia.

Modest alterations in obstetric practice could significantly reduce allegations of malpractice, the investigators concluded.

The largest number of malpractice suits (64) were related to fetal hypoxia, and 60 of these involved substandard care.

These cases accounted for the largest share of litigation costs ($89 million).


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