Expert Commentary

Q Where do patients pin the blame for adverse events?

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A Poor communication does convince some patients that an adverse event occurred when it did not, and that any adverse outcome could have been avoided. But in this study, clinical performance and communication problems both contributed substantially to adverse events, real or perceived.

Expert commentary

The litigious crescendo affecting ObGyn practice has reached deafening proportions in many states. Identifying the underlying causes of real or perceived adverse events is one way to minimize malpractice suits, improve women’s health care, and create a climate of safety for both physician and patient. Accordingly, White and colleagues analyzed 1 medical center’s internal review files for 90 consecutive ObGyn-related cases over 6 years. Though these files had been established by the center’s risk managers, they were not, technically speaking, “closed claims”; that term generally applies to cases involving legal action, rather than just risk-management consideration.

What investigators found

In 78% of cases, at least 1 factor that may have contributed to adverse events was identified. In 31% of cases, it was communication problems. Clinical performance issues were involved in 31% of cases, diagnostic issues in 18%, and patient behavior in 14%. Unfortunately, there appeared to be little physician representation on the team evaluating files. Instead, a group of nonphysician professionals assigned rather arbitrary inclusion/exclusion criteria to the cases and offered no specific clinical information about how each case was managed. In fact, whenever clinical issues were mentioned, the authors focused on communication.

Details on the clinical management of such adverse outcomes as shoulder dystocia would have been helpful, not to mention actual data on any lawsuits incurred. A short list of specific causes and suggestions for prevention also would have been helpful. The findings of this study cannot be generalized because they lack internal validity.

Talking about communication

Though White and colleagues tended to focus on communication rather than clinical events, communication was clearly an important factor. Even when no adverse medical outcome occurred, faulty communication between physicians and other caregivers, or between physicians and patients or their family members, caused obvious patient dissatisfaction and sometimes the threat of litigation.

Note to doctor: Accept responsibility

ObGyns are ultimately responsible for their patients’ care, and patients rightly expect focused attention with all diagnostic and treatment interventions governed by a well planned and coordinated strategy. When the physician fails to meet these expectations, the risk of litigation increases.

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