Eight tools for improving obstetric patient safety and unit performance

Related Article: How simulation can train, and refresh, physicians for critical OB events Robert Gherman, MD; Andrew Satin, MD; Roxane Gardner, MD, MPH

TOOL 3: INTERNAL AUDITS
It is a mantra in business that you can’t fix what you can’t measure. And while obstetric units usually keep track of such things as rates of cesarean section, elective induction at less than 39 weeks, and admission to the NICU, it is rare that data are kept on other extremely important information. For instance, how often is an induction started with no indication for it written in the admission note? How often is the vacuum or forceps applied with no note documenting the reason or the discussion of risks and benefits with the patient? How often does estimated fetal weight go unnoted in the medical record of a mother with gestational diabetes?

An audit program, either in computer format or with manual collection on paper, is a vital tool for each labor and delivery unit to use in assessing the quality of the care it provides. Such an audit, by covering a sufficiently large number of clinical data points, can give tremendous insight into the specifics of the unit’s performance over the range of obstetric care situations. It will show where things are being done well and where they are not. The audit becomes even more valuable if it is designed so that each of the measured data points can be evaluated for individual clinician performance as well as for the labor and delivery unit as a whole.

Similar audits also should be conducted in individual physician offices and obstetric clinics. Many of the errors that occur in providing obstetric care occur prenatally: tests not performed, lack of follow-up of known problems, or poor communication with patients or with the labor and delivery unit.

One of the major benefits of audit programs that are conducted on a regular basis—every 6 months or annually are common intervals—is that trends in performance in each area of care can be evaluated. As deficiencies are pointed out to providers, their compliance with best care practices should improve from cycle to cycle.

TOOL 4: BEST PRACTICE PROTOCOLS
Medicine is now well past the point where protocols are seen as “restrictive” or “advocating cookbook medicine.” Well-designed protocols summarize best practices derived from evidence-based studies and the consensus of obstetric experts. They serve as convenient reminders to physicians in various clinical situations so that these clinicians do not have to rely solely on what they happen to remember about caring for a given condition. Protocols also provide a certain uniformity of care, which in itself decreases the likelihood of errors being made.

Each obstetric department should have a set of protocols to cover the most common obstetric situations, such as:

• premature rupture of membranes
• instrumental vaginal deliveries
• oxytocin administration.

Each unit does not have to devise its own protocols; ACOG and nearby academic institutions are excellent sources for protocols that can be replicated and implemented so that they do not have to be created de novo.

Related Article: More strategies to avoid malpractice hazards on labor and delivery Martin L. Gimovsky, MD; Alexis C. Gimovsky, MD (January 2011)

TOOL 5: SAFETY CHECKLISTS
Just as well-designed protocols can serve as convenient reminders of best practices, low-tech physical checklists can be kept at nursing stations and in labor and delivery rooms to serve as reminders of best practices during obstetric emergencies. For instance, having a laminated set of easy-to-read protocols for postpartum hemorrhage, eclamptic seizure, maternal collapse, and shoulder dystocia in a delivery room can allow a charge nurse or other supervisor to check to make sure all proper procedures are being performed by the team actually administering care to a patient in crisis, with nothing important overlooked.

Related Article: Develop and use a checklist for 3rd- and 4th-degree perineal lacerations
 Robert L. Barbieri, MD (Editorial, August 2013)

TOOL 6: COMPLETE DOCUMENTATION
Almost as many lawsuits are lost because of poor documentation as are lost because of inappropriate medical care. The obstetric literature,¹ and my own experience with the medical-legal system, clearly demonstrate the need for appropriate, careful documentation of the events that transpire during patient care. Notes do not have to be especially long or verbose—but they must contain all relevant information and describe the obstetrician’s thinking at various decision points.

Documentation can be inadequate because of time constraints, poor understanding of the events that transpired, or simply a lack of remembering to include salient points that should be covered in a clinical note.

Clinicians can be prompted to include key aspects of care in the medical record by using prepared templates. Such templates are easy to fill out, remind clinicians to document information that would otherwise not get recorded, and result in a much more complete patient chart. By using a template, a clinician would never forget to record the head-to-body delivery interval after a shoulder dystocia or whether a fetal heart rate was obtained in the operating room just prior to starting a cesarean section.