and Education Services types of issues that are contributing to maternal mortality and lapses, such as most medication errors; rule-based errors resulting from lack of following effective protocols or standardization; and knowledge-based errors, whether they are caused by a lack of knowl- edge, or errors due to expert bias about a particular clinical situation. and safety is apparent. Obstetrics & Gynecology, claims involved substandard care and concluded: "Most money currently paid in conjunction with obstetric malpractice cases is a result of actual substandard care resulting in preventable injury." A separate bench- marking study, CRICO Strategies' 2010 Annual Benchmarking Report, judgment, 26 percent were a result of technical error, and more than a third (36 percent) were a result of miscommunication. the most frequent cause of perinatal mortality and morbidity. the health care industry as a whole, in part because health care professionals may be uncomfortable speaking up. A 2005 report by VitalSmarts and the American Association of Critical-Care Nurses, Silence Kills: The Seven Crucial Conversations for Healthcare, about teamwork and competency. percent) said they were concerned about a peer's competency, but only 12 percent had discussed it. In addition, 34 percent of nurses were concerned about a doctor's competence, but less than 1 percent had spoken about it. These findings don't change even when direct harm had been witnessed. Results were similar from the doctor's perspective: 81 percent of physicians were concerned about a nurse's competence, but only 8 percent had discussed it, and more than two-thirds of physicians were concerned about another doctor's competence, yet less than 1 percent had spoken about it. "kept quiet or remained passive" during questionable events, rather than confront a "known intimidator." interdepartmental training is therefore critical to improving maternal health and safety. Clinicians need not only to recognize cultural and disciplinary barriers to effective and open communication, but also be conscious of the tendency to assume others share similar views and knowledge when discussing clinical issues, and adjust for that bias, said Miller. This hesitancy to speak also can derail the intended safety efforts inherent in protocols and checklists. is afraid to speak up, the checklist goes out the window," Miller said. Moreover, because staff "non-experts" may be hesitant to speak up in certain situations, clinicians need to elicit their opinions to avoid "expert error," she said. types of critical conversations is Crucial Conversations: Tools for Talking When the Stakes Are High, by Kerry Patterson, Joseph Grenny, Ron McMillan and Al Switzler, Miller said. maternal mortality and morbidity, and knowledge gaps in normal labor and delivery care must be seen not simply as tragedies, but as opportunities-- chances to create safer systems and informed populations, two keys for improved health care in the United States. A systems approach, which avoids "blaming" and seeks prevention strategies to avoid future errors, can be particularly effective at improving maternal health and safety. |