Eight tools for improving obstetric patient safety and unit performance

Obstetricians, obstetric nurses, nurse managers, and obstetric department heads are almost always well-trained, hard working, highly motivated individuals dedicated to providing the best possible care for their patients. Nevertheless, errors in the provision of care are all too common.^1–3 Even though these errors are confined to a small percentage of patient interactions, they engender profound consequences: injuries to mothers or their babies, higher costs to treat associated complications, and medical-legal suits that can entangle both clinicians and plaintiffs for years.

Why do such errors occur when it is the goal of well-trained and dedicated practi-tioners to provide error-free care? There are several reasons:

• The provision of medical care in the early 21st Century is an enormously complex endeavor.
• Physicians and nurses are human beings and, therefore, do not—and never will—perform perfectly all the time, in every situation, with every patient.
• The systems within which care providers work and the tools with which they work are often suboptimal and inefficient and are not designed to maximize patient safety.
• Financial constraints on hospital systems and physician practices dictate that obstetricians and obstetric nurses care for as many patients as possible in limited periods of time.

How then can obstetrics professionals seek to eradicate or at least decrease the number of medical errors that occur during the provision of maternity care?

To accomplish this, we must address the core issues at the root of these medical errors. Solutions must be implemented to 1) simplify the often unnecessary complexity of delivering medical care and 2) create systems and tools that minimize errors and catch those that do occur before they can cause harm.

Yet, how is this to be accomplished? In this article, I describe eight tools developed over time by clinicians who have worked in the field of obstetric patient safety. These tools provide some answers and concrete starting points.

TOOL 1: CONTINUING EDUCATION
William Osler once said, “It is astonishing with how little reading a doctor can practice medicine, but it is not astonishing how badly he may do it.”

As the years out of residency and nursing school accumulate, clinicians—both obstetricians and obstetric nurses—find it all too easy to continue to practice pretty much the way they did during training. However, medical science changes, new protocols improve on the old, and new techniques and medications are introduced yearly into the practice arena. If a clinician is to deliver the best possible care, he or she has to keep abreast of these developments in obstetrics and refresh his or her memory from time to time about things learned long ago. Such acquisition of new and review of old obstetric knowledge can be achieved only through ongoing study.

There are many ways continuing education can be accomplished. You can read new editions of textbooks when they are published or follow an obstetric journal through its yearly cycle. Cutting-edge, clinically oriented, interactive courses in all major areas of obstetrics are available to clinicians online. The recertification criteria of the American College of Obstetricians and Gynecologists (ACOG), state licensing requirements, and individual obstetric department recredentialing requirements often mandate such continuing education.

TOOL 2: SIMULATION PROGRAMS
Most obstetric emergencies, especially the most dangerous ones, occur infrequently, making it difficult for the many members of any labor and delivery unit to have their skills sharply honed to best deal with them. This is less of a problem at busy institutions where, simply due to the numbers of patients cared for, such emergencies are encountered on a regular basis. But at smaller facilities they are, fortunately, rare. The only way a unit can maintain its competency to handle such situations when they do arise—and they will—is to practice them in simulation mode.

There is now an increasing amount of literature demonstrating that simulation programs are effective not only at improving the knowledge base of obstetrics providers but also at improving Apgar scores, reducing admissions to neonatal intensive care units (NICUs), and preventing brachial plexus injuries.⁴

An effective simulation program should contain the following features:

• a thorough, didactic review of the clinical aspects of emergency care for all of the major obstetric emergencies (postpartum hemorrhage, shoulder dystocia, eclamptic seizure, maternal collapse, and urgent cesarean section)
• practice drills for the above
• training in teamwork and communication skills
• frequent repetition, ideally with each major obstetric emergency being covered twice per year.

Many institutions have developed simulation training centers. While these can be excellent teaching facilities, something is lost if simulation training is not done on the actual unit where obstetricians and obstetric nurses will encounter emergencies. Simulation programs also should be time-efficient and should be scheduled to make it easy for obstetrics personnel to participate. For greater convenience and knowledge retention, it is better to have short simulation programs at frequent intervals than day-long programs once per year or every other year.