Category Risk Mitigation

In this blog, I’ll identify what an umbilical cord prolapse is, as well as provide an explanation as to why it is an obstetrical emergency.  Additionally, I’ll highlight some of the risk factors that can contribute to a cord prolapse, as well as provide insight as to the standards of care related to management

What is an umbilical cord prolapse?  An umbilical cord prolapse is identified when the umbilical cord exists the cervical os (opening of the cervix) before the presenting part (e.g. head, buttocks) of the baby.

Types:

1. Overt Prolapse: this occurs when the umbilical cord exists the cervix before the  presenting part of the baby (e.g. head, buttocks): the cord is palpable (felt) as a pulsating structure in the vagina.
   • See title image of overt cord prolapse
2. Occult Prolapse: this occurs when the umbilical cord exists the cervix with the fetal presenting part. The umbilical cord is not visible or palpable (felt) ahead of the presenting part of the baby.

Why is an umbilical cord prolapse an obstetrical emergency?  An umbilical cord prolapse is an obstetrical emergency related to the high rate of fetal morbidity and mortality. As a result of an umbilical cord prolapse, the blood vessels within the umbilical cord can become constricted which can cause fetal hypoxia, neonatal encephalopathy, cerebral palsy, and fetal death if not rapidly diagnosed, and managed.

What are the risk factors for an umbilical cord prolapse?  There are a number of risk factors that can predispose a woman, and her unborn baby to the sequela of an umbilical cord prolapse.  The risk factors include, but are not limited to, malpresentation of the baby (e.g. breech ‘buttocks’ presentation), multiple gestations (e.g. twins), polyhydramnios (excess fluid around baby), preterm rupture of membranes, intrauterine growth restriction, preterm delivery, fetal and umbilical cord abnormalities. 

It’s important to note that close to half of umbilical cord prolapse cases are attributable to iatrogenic (caused by medical examination, treatment) causes.  This includes amniotomy (artificial rupture of membranes) without an engaged fetal presenting part, attempted external cephalic version in the setting of ruptured membranes, amnioinfusion, placement of a fetal scalp electrode, insertion of an intrauterine pressure catheter (IUPC), or the use of a cervical ripening ballon.

What’s the standard of care regarding routine amniotomy? According to the American College of Obstetricians and Gynecologists (ACOG), women with normally progressing labor, and no evidence of fetal compromise, the performance of routine amniotomy is not clinically indicated unless required to facilitate monitoring.

Importance of rapid identification: In the presence of fetal bradycardia with ruptured membranes, this should prompt immediate evaluation for potential cord prolapse. Always consider the possibility of an umbilical cord prolapse in the setting of fetal bradycardia, or recurrent variable decelerations, especially if there is an onset of these decelerations that occur immediately after rupture of membranes.

Importance of rapid management: Funic decompression (relieving the pressure on the cord by elevating the presenting part of the baby) should be done manually (with a finger, or hand) by a medical provider or nurse.  This is done by placing a finger or hand in the vagina, and gently elevated the presenting part off the umbilical cord. There should be no further pressure placed on the umbilical cord as this may cause spasms of the vessels, and worsen the outcome. The mother should be placed in a Trendelenburg or knee-chest position as these positions can support cord decompression. If the umbilical cord is protruding outside of the introitus (opening of vagina), the umbilical cord should be covered in warm, moist wraps.  This is because the room temperate is colder than the temperature inside the uterus which can result in vasospasms within the umbilical cord, and cause fetal hypoxia. As soon as an umbilical cord prolapse is suspected or confirmed, efforts should be made to expedite delivery.  This is done typically by means of a  cesarean delivery.

Closing Thoughts: An umbilical cord prolapse is an obstetrical emergency requiring prompt identification, and management in an effort to minimize the risk of injury to the baby.  Incorporating multidisciplinary obstetrical emergency drills involving umbilical cord prolapse, and emergency cesarean delivery should be a part of regular simulation training.  Practicing role delegation, communication techniques during obstetrical emergencies, and maintaining knowledge of the standards of care related to management of umbilical cord prolapse will reduce the risk of injury to the baby as well as medical legal risk to care providers, and hospital systems.

Resources:

American Academy of Pediatrics & American College of Obstetricians and Gynecologists. (2017). Guidelines for perinatal care.

American College of Obstetricians and Gynecologists. (2021). Approaches to limit intervention during labor and birth.

Association of Women’s Health, Obstetric and Neonatal Nurses. (2021). Perinatal nursing.

Boushra, M., et al. (2023). National Institute of Health, National Library of Medicine.

COMMENT AND SHARE: have you been involved in a root cause analysis involving an umbilical cord prolapse? What was the outcome? What went well with the management? What were some of the opportunities for improvement? 

It’s estimated that approximately half of all paid obstetrical litigation claims involve allegations of Pitocin misuse.  Recognizing that Pitocin is a high alert medication warranting safe initiation, and management consistent with standardized evidence-based practices reduces patient harm, while reducing litigation risk for perinatal team members, and hospital systems. 

In this blog, I’ll identify what Pitocin is, and what it’s used for.  I’ll also address why Pitocin is considered a high alert medication.  Additionally,  I’ll highlight common allegations related to Pitocin management identified in past obstetrical related law suits.  I’ll close by offering some risk management approaches that can be integrated into practice.  

What is Pitocin? Pitocin is the synthetic (made by chemical synthesis) form of oxytocin, and serves as the most common labor induction agent.  Pitocin is chemically, and physiologically identical to endogenous oxytocin that is made, and circulated by the body.  Endogenous oxytocin  is synthesized by the hypothalamus in the brain, then is transported to the posterior lobe of the pituitary gland where it is then released into maternal circulation. Oxytocin is typically released in response to breast stimulation, sensory stimulation of the lower genital tract, and cervical stretching which results in uterine contractions.  The half-life of Pitocin is between 10-12 minutes with uterine response typically occurring within 3-5 minutes of intravenous (IV) administration.

What are high alert medications? High alert medications are defined as those bearing a heightened risk of harm when they are used in error, and that may require special safeguards to reduce the risk of error.

In 2007, Pitocin was added to the Institute for Safe Medication Practices (ISMP) list of high-alert medications due to the potential negative maternal, and fetal effects (patient harm) that can occur when used in error, such as inappropriate timing of administration, and/or excessive dosing. 

It’s important to note that Pitocin administration using pharmacological principles can be therapeutic during labor.  Pitocin is not a high-risk or dangerous drug, but rather a high-alert medication warranting safe initiation, and management.  If managed properly, Pitocin has no inherent risks. 

Examples of other high alert medications utilized in labor and delivery settings, include:

• Promethazine intravenously: an antihistamine, sedative, antiemetic commonly used to treat nausea, and vomiting
• Methotrexate: an immune-system suppressant used to treat ectopic ‘tubal’ pregnancies
• Magnesium Sulfate intravenously: used for the prevention of eclamptic seizures in pregnant women diagnosed with severe preeclampsia
• Insulin: used to treat diabetes in pregnancy, and during the course of labor
• Epinephrine (adrenaline): used for resuscitative efforts

General Incidence of Adverse Drug Events (ADEs): It has been reported that 400,000 Americans die annually as a result of medication errors.  In 2016, the CDC identified unintentional death, including medical mistakes, as the third leading cause of death in the U.S. The CDC’s Healthy People 2030 indicated that annual adverse drug events (ADEs) or harm resulting from medication errors, have led to 1.3 million emergency department encounters, 350,000 hospitalizations, and over $3.5 billion in excess medical costs.  ADEs remain a significant public health issue, with most instances being preventable. 

How do ADEs relate to the use of Pitocin? Pitocin is the most frequently used medication for labor induction, and augmentation.  Additionally, Pitocin is the medication most commonly associated with preventable adverse events during childbirth.  The risks of Pitocin are generally dose related, and include uterine tachysystole, excessive uterine activity, fetal compromise, neonatal acidemia, placental abruption, and uterine rupture.

Other types of Pitocin errors, and ALERTS include:

• Mistaken intravenous (IV) fluids with oxytocin in the management of IV fluid resuscitation during indeterminate or abnormal fetal heart rate (FHR) patterns and/or maternal hypotension
• Inappropriate elective (in the absence of a medical indication) administration to women < 39 completed weeks of gestation
• Failure to respond to high/low alerts:
  • The Joint Commission issued a sentinel event alert concerning medical devise alarm safety as alarm related events have been associated with permanent loss of function or death.  Among the most common contributing factors were improper alarm settings, alarm settings turned off inappropriately, alarm signals not audible to staff.
  • Risk Management Approach: Ensure FHR, and maternal vital signs alarm limits are set appropriately, and that alarms of turned on, functioning properly, and audible to staff. Follow hospital guidelines regarding prevention of alarm fatigue.
• Failure to reconnect the postpartum oxytocin infusion at the time of patient transfer, transition of care:
  • The Joint Commission issued a sentinel event alert related to managing the risk during transition.  Tubing connector standards are designed to prevent dangerous tubing  misconnections, which can lead to serious patient injury, and death.
  • Risk Management Approach: During the transition of care, be sure to trace the tubing, and catheter from the patient to the point of origin before connecting or reconnecting any device or infusion, at any care transition (such as a new floor, unit, hospital, or service), and as part of the hand-off process; route tubes, and catheters with different purposes in different standardized directions; when there are different access sites, or several bags are hanging, label the tubing at the distal and proximal ends; use tubing, and equipment only as intended; and store medications for different delivery routes in separate locations.
• Failure to adhere to sterile technique at the time of initiating IV access:
  • The Centers for Medicare and Medicaid Services considers vascular catheter-associated infection to be a hospital acquired condition because it can be reasonably prevented using a variety of best practices.
  • Risk Management Approach: Follow evidence-based infection prevention practices, such as performing hand hygiene, maintaining sterile no-touch technique when preparing, and administering infusions, and performing a vigorous mechanical scrub of needless connectors to reduce the risk of vascular catheter-associated infections.

Risk Management Perspectives: It’s estimated that approximately half of all paid obstetrical litigation claims involve allegations of Pitocin misuse.

• Common Allegations:
  • initiation of Pitocin in the absence of evidence of fetal well-being.  Failure to complete a non-stress test prior to initiation of Pitocin.
  • failure to accurately assess maternal-fetal status during labor induction.  Continuous fetal monitoring not performed; failure to assess, and document fetal heart rate, and uterine activity per organizational policy, and standard of care.
  • excessive doses of Pitocin resulting in uterine tachysystole, with or without an indeterminate or abnormal FHR pattern.
  • failure to discontinue or decrease Pitocin in the presence of a Category II and/or Category III FHR tracing unresolved with intrauterine resuscitation.

 Pitocin management also serves as a source of clinical conflict between nurses, midwives, and physicians during labor. Such clinical conflict increases the risk of patient harm, and litigation. By developing a shared mental model across specialties, and incorporating agreed upon standardized policies, clinical conflict, and inter-observer variability is reduced leading to positive birth outcomes, as well as less liability risk for the perinatal teams, and hospital systems.

Additional Risk Management Strategies:

• Prior to the administration of Pitocin, have another nurse perform a double check (2^nd RN verification) to verify patient identity, and to make sure you have the correct medication in the prescribed concentration, the medication indication corresponds with the patient diagnosis, the dosage calculations are correct, and the dosing formula used to derive the final dose is correct, the prescribed route of administration is safe, and proper for the patient, the pump settings are correct, and the infusion line is attached to the correct port.
• Utilize pre-oxytocin, and in-use oxytocin safety checklists.
• Have standardized policies for oxytocin dosing, definitions, and interventions for indeterminate, and abnormal FHR patterns, as well as excessive uterine activity that are agreed upon by all members of the perinatal team, used to guide management, and consistent with the standards of care.
• Ensure completion of a full assessment of uterine activity in labor including contraction frequency, duration, intensity or strength, resting tone, and relaxation time.
  • 2008 NICHD workshop report: “uterine contractions are quantified as the number of contractions present in a 10-minute window, averaged over 30 minutes.  Contraction frequency alone is a partial assessment of uterine activity.  Other factors such as duration, intensity, and relaxation time between contractions are equally important in clinical practice to safe guard fetal, and uterine acid-base status”.
  • Ensure hospital systems are not guided by limiting tachysystole protocols exclusively, but rather on excessive uterine activity protocols.
    • consider the clinical context (stage/phase of labor, maternal, and fetal risk factors, labor progress)
• Ensure that nurses and Ob providers are properly trained.  Implement multidisciplinary education related to electronic fetal monitoring, assessment of uterine activity, and Pitocin management.
• Maintain a 1:1 nurse-patient ratio while managing Pitocin.
• Real-time, and complete documentation including a full evaluation of uterine contractions, and a complete assessment of the fetal status, using a flowsheet or progress note.
• Be knowledgeable about fetal heart rate, and uterine activity physiology, including the significance of adequate relaxation time between contractions.
• Remain current with your professional organization, and remain current with organizational literature.

The purpose of this blog is to educate, and inform in an effort to promote patient, and perinatal team safety, promote positive birth outcomes while reducing the incidence of obstetrical related medical malpractice lawsuits by lowering the recurrence risk of errors.

References

American College of Obstetricians and Gynecologists, 2020. ACOG Practice Bulletin No. 107: Induction of labor.

Centers for Medicare and Medicaid Services, 2020. Condition of participation: 42 C.F.R.

Centers for Disease Control and Prevention, 2024. Leading causes of death.

Institute for Safe Medication Practices, 2024

Makary, 2016. Medical error – The third leading cause of the death in the U.S.

Simpson, et al., 2021. AWHONN Perinatal nursing, 5^th ed.

The Joint Commission, 2021. Standards NPSG. Comprehensive accreditation manual for hospitals.

U.S. Department of Health and Human Services. Healthy People 2030.

COMMENT AND SHARE: Do you have experience with an adverse drug event related to Pitocin? What was the outcome? Were organizational, or system changes made to minimize the risk of recurrence?

You can learn so much from the metadata in the electronic health record (EHR).  Metadata is data, about data.

Example: data entered, patterns of missing data, when data was entered, who entered it, who viewed it, how long it was viewed for, and whether it was modified.

Metadata can identify incidences of errors, as well as patterns of patient care delivery (i.e., recurrent late entries)

Metadata is discoverable per the Federal Rules of Civil Procedures. This means that attorneys can acquire access to EHR information, including the metadata, through the discovery process. Metadata is typically  obtained by a computer-generated record of audit trails showing user access and actions.  

Providers Can Minimize Risk by Effectively Documenting: During the litigation process, metadata can play an integral role in determining the credibility of evidence, including healthcare provider’s testimony, and documentation.

• Avoid documentation gaps
• Don’t copy and paste text from one patient’s EHR to another
• Use templates and checklists cautiously
• Do not share your password
• Make any changes to the record as soon as possible, per organizational policy
• Know that what you view is recorded
• Document referrals and notifications of other nurses about changes in a patient’s condition

Metadata analysis can support — or not support — a lawsuit. Frequent errors, and errors of omission can negatively impact a healthcare providers credibility in court.  Contrary, metadata that demonstrates  complete, and accurate documentation can help exonerate healthcare providers by bolstering their credibility, and providing evidence that adherence to organizational policies, and procedures, as well as  standards of practice were followed.

RESOURCES

• AHIMA. E-discover litigation and regulatory investigation response planning: Crucial components of your organization’s information and data governance processes. n.d. https://bok.ahima.org/doc?oid=107115#.ZByfmBXMJhE
• Barrett M, DeAngelo TR, DeAngelo JG. E-discovery: Metadata analysis in medical malpractice litigation. The Legal Intelligencer. 2020. Commentary. https://www.law.com/thelegalintelligencer/2020/04/09/e-discovery-metadata-analysis-in-medical-malpractice-litigation/?slreturn=20230223103325
• Conn J. Making IT legal-size; As electronic health-record systems become more complex, so do the issues involving the legal status of those records. Modern Healthcare. 2008;38(20),
• Gardner E. The weight of the I.T. evidence; why EHRs won’t reduce your malpractice premiums. Health Data Management. 2013;21(10).
• Hansen MD, Pratt TJ. Follow the audit trial: The impact of metadata in litigation. Defense Counsel J. 2017;84(3).
• NSO, 2024. What nurses need to know about metadata, documentation, and legal liability. https://www.nso.com
• Shwayder JM. Electronic records and metadata: Old and new liability risks: Metadata from an EHR form an audit trail of activity, which can make or break a malpractice case. Cont OB/GYN. 2018;63(9).

P.S. COMMENT & SHARE: What has been your experience utilizing metadata to support your medical legal cases?

In this blog, I’ll be introducing a maternal sepsis case study, followed by supportive content to enhance the readers understanding of the incidence of maternal sepsis in the U.S., causes, risk factors, and complications that can occur as a result of maternal sepsis. I’ll provide information on the recommended screening, diagnostic criteria, as well as assessment, and treatment  recommendations. 

Case Study: A 38-year-old woman, gravida 6 para 5, with an unremarkable past medical history presented to labor and delivery in active labor at 39 weeks of gestation and delivered vaginally shortly thereafter. Delivery was uneventful, without regional anesthesia and without perineal tears nor other complications. Twenty-four hours after delivery, the patient developed isolated left lower quadrant pain. Physical examination, abdominal ultrasound, and laboratory tests including complete blood count and basic metabolic panel were unremarkable, and the pain subsided after a bowel movement. On the following day, abdominal pain worsened, while the patient remained afebrile and was hemodynamically stable. Clinical assessment and physical examination of the pelvis and abdomen by the gynecological and surgical teams were unremarkable and revealed no acute distress; the abdomen was soft and non-tender on palpation, and bowel sounds were normal in all four quadrants. Notably, there was a significant discrepancy between the symptoms (referred abdominal pain) and the objective clinical findings. An abdominal and pelvic CT scan demonstrated normal post-partum uterus, endometrium and pelvic organs without signs of acute pathology. A large fecal burden throughout the colon was seen, suggesting possible constipation. Subsequently, 60 h after birth, her clinical condition deteriorated as the patient developed tachycardia with 130 beats per minute, tachypnea with 20 breaths per minute, and blood pressure of 103/65 mmHg. Laboratory values included a white blood cell count of 1.5 × 10⁹/L and C-Reactive Protein (CRP) of 27.1 mg/dl and Lactic acid of 4.05 mmol/L. Creatinine, liver-function tests, and electrolytes were within the normal range. Due to a high clinical suspicion of puerperal sepsis at this point, a wide-spectrum antibiotic regime of ampicillin, clindamycin and gentamicin was initiated, and the patient was transferred to the intensive care unit (ICU). Shortly afterward, the patient became hemodynamically and respiratorily unstable and required sedation, mechanical ventilation, and the use of inotropes to maintain adequate blood pressure. Laboratory results revealed worsening leukopenia, thrombocytopenia, and lactic acidosis. A post-contrast computed tomography scan showed an enlarged uterus with abundant periovarian and peritoneal fluid. Since the presence of pus in the abdomen was suspected and due to the severe clinical deterioration, an emergency exploratory laparotomy was executed, during which 600 ml of thick yellowish-white abdominal fluid was aspirated. The uterus and both ovaries were swollen, necrotic, and covered with fibrin, therefore a total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. Ovarian preservation was not possible because of severe necrosis. Gross findings of the post-operative pathological specimen showed an ischemic and partially necrotic uterus, while microscopic examination of the uterus revealed a severe acute inflammatory process with necrotic myometrium and bacterial colonies, confirmed later to be Streptococcus pyogenes on blood-agar medium culture. Post-operatively, the patient underwent a prolonged recovery period and was discharged without any further obstetrical or gynecological complications (Kabiri D, et al., 2022. Case report: An unusual presentation of puerperal sepsis. Front Med).

 

What is Maternal Sepsis:  Maternal sepsis is a life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion, or postpartum period.

The most common pathogens that cause maternal sepsis include Streptococcus pyogenes, Escherichia coli, Staphylococcus aureus, Group B Streptococcus, Streptococcus pneumoniae, Methicillin-resistant Staphylococcus aureus (MRSA), Clostridium septicum, and Morganella morganii.

Clinical Presentation: The normal changes of pregnancy complicate identification, and treatment of maternal sepsis. Pregnant patients appear clinically well prior to rapid deterioration with the development of septic shock, multiple organ dysfunction syndrome, or death.  This is due to pregnancy-specific physiologic, mechanical, and immunological adaptations (JAMA, 2021). 

National Statistics: Maternal sepsis is the second leading cause of pregnancy-related death in the United States.  Among all pregnancy-related deaths in the U.S., 12.5% are attributed to sepsis (JAMA, 2021). It is estimated that 4 to 10 per 10,000 live births are complicated by maternal sepsis (ACNM, 2018). Rates of pregnancy-associated sepsis are increasing in the U.S., as are rates of sepsis-related maternal deaths.

*Approximately 40% of maternal sepsis cases are preventable with early recognition, early escalation of care, and appropriate antibiotic treatment (Kabiri D. et al. 2022).  

Risk Factors: Risk factors for maternal sepsis include advanced maternal age, preterm premature rupture of the membranes (PPROM) and preterm delivery, multiple gestation pregnancies, cesarean delivery, retained products of conception, post-partum hemorrhage, and maternal comorbidities.  It’s important to note that maternal sepsis occurs in patients without risk factors.

Screening & Diagnostic Criteria: The use of a maternal early warning system (MEWS) is recommended.  This is a set of specific vital sign, and physical exam findings that prompt a bedside evaluation and/or work-up (see ACOG’s MEWS example below)

Complications of Maternal Sepsis: Complications include, but are not limited to, maternal death, fetal death (pregnancy loss),  preterm premature rupture of membranes, preterm labor and birth, preterm delivery complications of the newborn, lower newborn weight, cerebral white matter damage, cerebral palsy, and neurodevelopmental delay.

Management Recommendations: Survivability requires early detection, prompt recognition of the source of infection, and targeted therapy.

*Delayed antibiotics > 1 hour = increased mortality

How The American College of Obstetricians and Gynecologists’ (ACOG) Safe Motherhood Initiative (SMI) Sepsis Bundle Reduces Maternal Morbidity: The SMI is a collaborative initiative between ACOG and NYSDOH to improve patient safety and raise awareness about risk factors that contribute towards maternal morbidity & mortality.  The SMI supports provider readiness, and recognition through the availability of education, standardized sepsis work-up criteria and diagnostic tools. The SMI supports timely provider response, and reporting by the availability of a standardized sepsis management algorithm, recommended criteria for consultation, and transfer to a higher level of care, and case debriefing tools.

Resources:

ACNM, 2018. Recognition and Treatment of Sepsis in Pregnancy

ACOG, 2020. Maternal Safety Bundle for Sepsis in Pregnancy

JAMA Network Open. 2021;4(9): Perinatal Outcomes Among Patients with Sepsis During Pregnancy

Kabiri D, Prus D, Alter R, Gordon G, Porat S, Ezra Y. 2022. Case report: An unusual presentation of puerperal sepsis. Front Med 15:9.

P.S. Comment and Share: What is your experience with maternal sepsis?

If you are in need of a medical legal expert specific to a maternal sepsis case, contact Barber Medical Legal Nurse Consulting, LLC. Email: Contact@barbermedicallegalnurse.com

In this blog, I’ll be reviewing the data trends and leading causes of obstetrical (Ob) related malpractice claims.  Additionally, I’ll review identified barriers to adopting evidence-based standards of care while contrasting effective implementation strategies.  I’ll conclude with a summary of the 2020 Joint Commission Perinatal Safety Standards and highlight how the required standards align with the Ob related malpractice trends.   

Trends / Statistics: The average Ob malpractice payment is $947,000 which is more than twice that of other clinical areas (Crico, 2010).  The dollar amount reserved for current and future payment is usually 25% – 35% of the total financial liability cost to the hospital and healthcare system. 

Between 2007-2016, Specific to Ob/Gyns (whose rate is historically higher than the average for all MDs), the risk of having a malpractice case filed against them dropped by 44% (Crico, 2018).

It’s suggested that the drop in claims is a result of quality improvement (QI) initiatives such as training to improve team communication during labor and delivery, and multidisciplinary education on fetal heart rate tracings.

Between 2007-2016, defendant rates declined most steeply in Ob/Gyn.  It’s suggested that the declines correlate with long-term safety interventions (Crico, 2018).

There is a risk of permanent and catastrophic damages that can occur as a result of Ob/Gyn medical errors.  The Ob/Gyn specialty incurs significantly disproportionate financial losses when compared to the total number of medical malpractices cases. 

Most Common Ob Malpractice Claims and Contributing Factors:  The majority of Ob related malpractice cases involve birth asphyxia, shoulder dystocia, intrauterine fetal demise and maternal hemorrhage (AWHONN, 2014).

Contributing Factors:

• Clinical judgement: inadequate patient assessment, inappropriate management of pregnancy, failure to timely diagnose and treat a non-reassuring fetal heart rate tracing, inappropriate management of the 2^nd stage of labor via operative vaginal birth
• Technical skills: inexperience with procedures
• Communication: provider-provider communication breakdowns, inadequate consent, hierarchical issues

According to FOJP (Hospital Insurance Company), a growing concern has emerged specific to permanent injuries related to shoulder dystocia cases.  FOJP found that while clinical judgment factors were trending downward in labor & delivery cases, technical issues were trending upward.  The proposed action plan provided was specific to teamwork and simulation training.

It is common knowledge that defensibility is enhanced when care is consistent with current evidence-based standards of care.  Despite this knowledge, many organizations continue to struggle with implementing policies, QI and process improvement (PI) initiatives that are consistent with current standards.

Common Barriers to Adopting Evidence-Based Standards of Care:

Leadership Barriers

• Lack of knowledge specific to QI/PI and QI/PI data analysis
• Leadership attitudes
• Leadership practices: not consistently applying new operations, lack of sustainability efforts, lack of time and resources

Clinician Barriers

• Lack of clinician knowledge specific to their own practices, lack of audit & feedback processes, novice status, lack of knowledge about QI/PI projects
• Clinician attitudes: not motivated to change, desires autonomy
• Clinician practices: forgot about QI/PI project, changes add more work or slow down work flow

Characteristics of the QI, or PI Project

• Positive or negative effect on clinician income or time
• Complexity of the QI/PI project

Implementation Climate

• Type of hospital
• Amount of resources
• Type of patients

Strategies for Successful Implementation and Sustainability of Evidence-Based Standards of Care:

Educational strategy: grand rounds, conferences, simulation training, competency tests and demonstrations, on-line learning

Data strategy: audit and feedback methodology to support individual and group data sharing of performance against benchmarks, public release of data focused on outcomes reported openly to the community

Discourse strategy: meetings, review of academic research, reminders via checklists, order sets, newsletters, bulletin boards, emails, rewards for reaching a goal, disciplinary discussions providing feedback specific to performance not aligning with required expectations

How the 2020 Joint Commission Perinatal Safety Standards Align with the Ob Related Malpractice Trends: All hospitals accredited by the Joint Commission are required to comply with the 2020 Joint Commission Perinatal Safety Standards.  The safety standards were developed in response to the leading causes of perinatal morbidity and mortality: maternal hemorrhage and severe hypertension/preeclampsia.

A number of the required elements of performance center around:

• The development of written evidence-based procedures for managing Ob emergency events (educational and discourse strategy).

• Providing role-specific education to all staff and providers who treat pregnant and postpartum patients about the organization’s procedures at a minimum every two years (educational strategy).

• Supporting annual multidisciplinary simulation drills to determine system issues as a part of on-going QI efforts (educational strategy).

• Completing regular reviews of severe maternal morbidity and mortality cases to evaluate effectiveness of the care, treatment, and services provided by the response team during the event (data strategy).  

Knowledge is power, power is change.  We, as a multidisciplinary group of clinicians, and legal representatives, need to be the change we wish to see by propelling healthcare policies that are consistent with current evidence-based standards. 

References

AWHONN, 2014. Perinatal Nursing 4^th ed.

AWHONN, 2021. Perinatal Nursing 5^th ed.

Crico, 2010. CBS Benchmarking Report – Medical Malpractice in America

Crico, 2018. CBS Benchmarking Report – Medical Malpractice in America

The Joint Commission, 2019. Provision of Care, Treatment, and Services standards for maternal safety

P.S. Comment and Share: Have you been involved in developing and/or implementing a new perinatal policy, QI, or PI initiative in response to the 2020 Joint Commission Perinatal Safety Standards?  If so, what was the policy/QI/PI initiative and how has it improved outcomes?