Stop. Look. Listen! Page 12

Perinatal Safety:

A Systems Approach and

Opportunities for Improvement

Lisa Miller, CNM, JD

Perinatal Risk Management
and Education Services

ooking at systems, rather than individuals, can help identify the
types of issues that are contributing to maternal mortality and

morbidity at an organizational level--distinguishing among "slips" or
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.

The need to address the issue of medical errors in maternal health
and safety is apparent.

A review of more than 100 hospitals, published in a 2008 issue of
Obstetrics & Gynecology,

looked at perinatal closed claims from a single

insurer over a five-year period. It found that 70 percent of obstetrics
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,

showed 77 percent of cases were a result of substandard clinical
judgment, 26 percent were a result of technical error, and more than a
third (36 percent) were a result of miscommunication.

The Joint Commission has found communication failure to be
the most frequent cause of perinatal mortality and morbidity.

Communication problems are detracting from a culture of safety in
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,

found

that clinicians generally are not comfortable addressing concerns
about teamwork and competency.

For example, more than half of nurses surveyed for the report (53
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.

Three years later, a Joint Commission Sentinel Event Alert

showed

not much had changed: approximately 40 percent of clinicians had
"kept quiet or remained passive" during questionable events, rather
than confront a "known intimidator."

Improving communication skills through multidisciplinary and
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.

"Checklists are only as good as the people using them. If the person
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.

An excellent resource for helping individuals learn to handle these
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.

Findings on pre-term birth rates,
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.