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Near-Miss Reporting and the OB Right Program


Hospital safety issues have been widely reported and have received significant attention recently. However, solutions have been slow in coming. Thus, the ongoing challenge of creating the safest labor and delivery environments possible has been left with obstetricians. Although the problem is daunting, there are many steps that obstetric and gynecologic practices can take on their own that will reduce adverse events in labor and delivery as well as optimize maternal-fetal outcomes.

Separate reports published almost a decade ago by the Institute of Medicine and the American Hospital Association estimated that 44,000–98,000 patients die each year from errors made during hospital stays.

That higher death rate accounts for almost double the number of people who die in motor vehicle accidents each year in this country, and double the number of women who die annually from breast cancer, according to the Centers for Disease Control and Prevention.

The problem is so severe that Dr. Mark R. Chassin, president of the Joint Commission (an independent, not-for-profit organization that accredits and certifies more than 15,000 health care organizations and programs in the United States), noted recently that the chance of any of us being injured from simply being in a hospital and not as the result of an illness is 40% greater than the likelihood of an airline mishandling our luggage.

The problem of inconsistent and dysfunctional clinical patterns of care in both the inpatient and outpatient settings is even more alarming. One large study involving the review of 18,000 patient charts found that only 55% of patients received care in keeping with current best practices (“Epidemic of Care: A Call for Safer, Better, and More Accountable Health Care.” San Francisco: Jossey-Bass, 2003).

Approximately 5 years ago, the Joint Commission examined all perinatal “sentinel” events across the country in all types of institutions, and found that 72% of such events were linked to breakdowns in communication.

Other identified root causes included staff competency (47%), staff orientation and training (40%), inadequate fetal monitoring (34%), unavailable equipment or drugs (30%), and physician-credentialing issues (30%).

Major issues of concern in the labor and delivery setting involve the fetal heart rate tracing, iatrogenic prematurity, shoulder dystocia, and operative delivery, as well as all the verbal and written communications that are involved with each of these areas.

An American College of Obstetricians and Gynecologists survey noted that the fetal heart tracing accounts for the majority of liability claims pertaining to labor and delivery.

Labor and delivery safety programs should therefore focus primarily on these issues, and on the following:

▸ Simplifying and standardizing protocols for care.

▸ Adopting evidence-based practices.

▸ Relying more on simulation and training.

▸ Working together as a team to accomplish defined goals.

Near-Miss Reporting

The real crux of any patient safety initiative—and the element that goes hand-in-hand with each of these aspects of a program—is a “near-miss” reporting system. This is a concept that medicine borrowed from the airline industry; it involves reporting any occurrence that could have resulted in an adverse event.

A near-miss reporting program is nonpunitive, and empowers everyone involved in the care of a patient to report events and happenings that they believe have the potential to cause problems for patients. Reports are made before injury happens and are reviewed in a blame-free environment. Systems can then be analyzed and modified to minimize recurrence of these events.

In fall 2005, a collaborative effort among the academic faculty at Eastern Virginia Medical School (EVMS) in Norfolk, the obstetric community faculty in that city, and Sentara Healthcare established the OB Right program, with the mission of minimizing iatrogenic injury to the mother and infant and reducing adverse patient safety events at labor and delivery. The “near-miss report form” used by the patient safety program at EVMS and Sentara Healthcare asks for descriptions of events that were “out of the ordinary” or “made you uncomfortable.” It also asks for suggested solutions.

The program has been enormously successful. Over the past 3 years, almost 230 near-misses have been reported by our physicians, residents, and nurses. Echoing the 2004 Joint Commission report, our near-miss reports have shown us that communication issues account for at as many as 60% of these potentially dangerous situations. These reports also have helped solidify a patient safety approach that gives special attention to fetal heart rate monitoring, shoulder dystocia, iatrogenic prematurity, and operative deliveries.

Setting Up a Program

At the time the OB Right program was established, it encompassed two hospitals in the Sentara Healthcare System: Sentara Norfolk General Hospital (the academic tertiary hospital of EVMS) and Sentara Leigh Hospital, (a community hospital in Norfolk that has no 24-hour in-house obstetric coverage). The purpose of including both hospitals was to ensure that the program is successful in both settings.

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