Teamwork Cuts Obstetric Adverse Events by Half


DALLAS — A comprehensive patient-safety strategy cut obstetric adverse events in half and lowered malpractice costs by nearly 40% at the Yale-New Haven Hospital.

The composite rate of adverse events in the obstetrics and gynecology department was 3% in October 2004 when the project started but decreased to 1.5% by February 2007, Dr. Edmund Funai said at the annual meeting of the Society for Maternal-Fetal Medicine. The difference was significant.

In the summer of 2004, only 15% of nurses and 40% of physicians reported that teamwork was high in the department, whereas 75% of both groups felt that teamwork was high in the department in the fall of 2006.

Malpractice premiums dropped significantly from a high of $95,000 per year in 2003 to a low of $53,000 in 2007.

“Granted this is a very complex marker, which is subject to the vagaries of the local legal climate; however, if I showed you a similar slide that reported new [malpractice] cases in each year, you'd see a similar trend,” said Dr. Funai of the department of obstetrics, gynecology, and reproductive services, Yale University, New Haven, Conn.

The initiative included these primary components:

▸ An independent review of the service.

▸ Creation of a dedicated patient-safety nurse position with duties such as anonymous adverse event reporting.

▸ Appraisal of teamwork using a safety-attitude questionnaire.

▸ Protocol-based standardization of 34 common procedures, such as administration of oxytocin.

▸ Mandatory team training for all staff.

▸ Adoption of National Institute of Child Health and Human Development terminology for interpretation of fetal heart-rate monitoring, culminating in a national certification exam.

▸ Multidisciplinary oversight by a department-based patient safety committee on 14 individual outcomes such as 5-minute Apgar less than 7, fetal birth injury, and unexpected NICU admission.

Dr. Funai pointed out that adverse events occur in roughly 3% of all hospital admissions, with 50% thought to be preventable errors and 10%–14% of errors resulting in death.

Institutions put barriers in place to prevent these errors, but inevitably holes in the system occur.

“When an adverse event occurs, it is rarely the fault of the individual, but a breakdown of the system, and this is why it is crucial to move from a culture of blame to a culture of safety,” he said.

Audience reaction to the presentation was strong, with some members lauding the results and others questioning whether the findings of the observational study are generalizable. Some questioned whether the findings could be attributed to greater attention to quality rather than to the patient-safety strategy.

“I do agree there is certainly a Hawthorne effect because we were focused on quality and talking about it,” said Dr. Funai, who reported that he had no financial conflicts of interest or funding sources for the study.

He acknowledged there might be issues of generalizability.

Yale University is a large academic institution with substantial resources that were able to support the cost of the patient-safety nurse at a yearly salary of $125,000 plus fringe benefits, the safety-attitude questionnaire, and the fetal monitoring certification process, and other institutions might not have such resources available to them, he said.

The study was limited by its uncontrolled observational design—raising questions of causation versus association, the inability to assess the effect of individual interventions, and the possibility that undocumented improvements in communication and oversight as well as outside factors might have affected outcomes, Dr. Funai said.

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