Safety in Pregnancy Care

Learning Objectives

• Discuss the need for a patient safety focus and team-based approach to pregnancy care.
• Demonstrate teamwork tools that improve safety, including closed-loop communication and the application of evidence-based mnemonics.
• Explain risk-management issues in obstetrics and possible solutions (The Five Cs).

Introduction

• US Airways flight 1549 landed on the Hudson River in 2009; all 155 aboard survived due to teamwork and communication.
• Preflight training and simulations prepared airline personnel.
• Effective communication occurred between pilot, crew, passengers, ground control, and rescuers.
• The odds of being killed in an airline crash have decreased to 1 in 4.7 million flights due to Crew Resource Management (CRM).
• CRM focuses on safety, protocols, communication, and checklists.
• Aviation safety strategies like CRM can be applied to medical care, focusing on saving lives through teamwork, communication, and system improvement (patient safety).
• The Institute of Medicine defines patient safety as "the prevention of harm to patients."

Advanced Life Support in Obstetrics and Patient Safety

• The Advanced Life Support in Obstetrics (ALSO) program focuses on patient safety.
• Since 1991, ALSO courses have promoted interdisciplinary teamwork among pregnancy-care providers in over 60 countries.
• Participants include physicians, midwives, nurses, residents, and students from various settings.
• Rural and urban providers can learn from each other's experiences.
• In 2002, ALSO added a Safety in Maternity Care chapter, emphasizing teamwork and systems issues.
• In 2022, the chapter was renamed Safety in Pregnancy Care for gender inclusivity.
• ALSO promotes safety through a standardized approach to obstetric emergencies.
• Standardization reduces variation, duplication, and increases reliability.
• Knowledge, skills practice, and mnemonics reduce errors and morbidity/mortality.

Importance of Safety in Pregnancy Care

• Approximately 303,000 people died from childbirth-related causes worldwide in 2015.
• A UN Sustainable Development Goal aims to reduce global maternal mortality to fewer than 70 per 100,000 live births by 2030, from 216 per 100,000 live births in 2015.
• Childbirth accounts for 11% of hospital admissions; cesarean delivery is the most common operative procedure in the US.
• In the US, there were over 3.6 million births in 2021, with more than 80,000 adverse obstetric events.
• Public health improvements, technology, targeted drugs, increased training, and regionalized perinatal care have reduced childbirth-related risks.
• Maternal mortality has increased in the US since 1990, unlike most countries.
• California's success in decreasing maternal mortality is attributed to patient-safety bundles, now being implemented nationwide.
• The Joint Commission reports poor communication as the root cause in 48% of maternal and 70% of perinatal sentinel events (2004-2014).
• Improved communication and teamwork among pregnancy care providers can save lives.
• ALSO courses teach these skills and practice them in simulated settings.
• Even highly trained professionals make mistakes; most errors don't result in harm, but preventable medical errors are the third leading cause of death in the US.
• A 2013 study found that between 210,000 and 400,000 Americans die each year of preventable medical errors, with nonlethal errors being 10 to 20 times more common.
• Seven percent of hospital patients experience serious medication errors.
• Medical errors cost an estimated $$17 billion to $29 billion annually.
• Human failures cause 80% to 90% of errors, according to The Joint Commission.
• Recognizing the connections between procedures, technology, and humans is essential.
• Simulation and team-based training are components of this strategy.
• Team training has been required by The Joint Commission since 2003.
• Hospitals must incorporate team training methods for interdisciplinary collaboration.
• Staff must participate in education and training that incorporate team communication, collaboration, and coordination of care.
• Although some adverse outcomes are unavoidable, many result from communication and system problems.
• One study showed that 87% of adverse events were preventable and that poor teamwork, protocol violation, and staff unavailability were the most common problems.
• Most labor and delivery units involve so many clinicians that a patient care team rarely involves the same people, leading to high variability in team membership.
• All healthcare team members should be trained in standardized communication techniques.

Evidence for Teamwork Improving Outcomes

• Evidence shows that improving teamwork improves outcomes.
• A systematic review of randomized controlled trials (RCTs) found that simulation-based teamwork training improved team performance in 3 of 3 RCTs and patient morbidity in 3 of 4 RCTs.
• A 2020 Cochrane review found that simulation-based obstetric team training probably reduces trauma after shoulder dystocia (relative risk (RR) = 0.50; 95% CI=0.25-0.99; 1 RCT; moderate-strength evidence) and probably reduces the number of caesarean deliveries (RR = 0.79: 95% CI = 0.67-0.93; 1 study; N = 50,589; moderate-certainty evidence).
• The University of Minnesota and the Fairview Health System in Minneapolis have provided an evidence-based framework for the dissemination of in-situ simulations to enhance interdisciplinary communication and teamwork.
• A 2011 study documented a persistent and statistically significant 37% decrease in perinatal morbidity at a hospital with standardized teamwork training and regular in-situ simulations compared with no change at a hospital with standardized teamwork training alone and a control hospital where neither was taught.
• The Weighted Adverse Outcome Score (WAOS) and Maternal Severity index improved 50% after the implementation of teamwork training on a labor and delivery unit at the Harvard-affiliated Beth Israel Deaconess Medical Center.
• An RCT assessing the American Academy of Pediatrics Neonatal Resuscitation Program course with and without additional teamwork training showed that individuals who underwent standardized teamwork training in conjunction with the course demonstrated improved teamwork behavior at the end of the course.
• The best team training in the world will not yield the desired outcomes unless the organization is aligned to support it.

Essential Elements of a Strong Pregnancy Care Team

• Childbirth is an intense physical and emotional experience, and the pregnant person's family members and support network often have an important and integral role.
• The health care team includes the birth attendant, nurses, support personnel (eg, nursing assistants), and consultants.
• The presence of a doula or professional support person and continuous labor support can increase the probability of spontaneous vaginal delivery and reduce the need for drugs and instrument delivery.
• Clinician strategies for supporting pregnant people include listening, anticipating potential problems, discussing options, reviewing birth plans, conferring at each decision point, and assessing for entrenched health beliefs, expectations, and concerns.
• Patient-centered interviewing, caring communication skills, and shared decision-making will promote effective patient-provider communication.
• Involving pregnant people in their own care can improve outcomes, satisfaction, and adherence.
• Clinician strategies for working with a pregnant person's family and support network include developing relationships with the pregnant person's partner and/or family, encouraging attendance at childbirth classes, and acknowledging existing anger or anxiety.
• The health care team can improve patient safety and satisfaction through effective communication, a readily available birth attendant, care teams, and consultants who are willing to assist in a timely manner.
• All team member contributions should be respected and encouraged.
• Impediments to team function include personality conflicts, competitive pressures, fixed beliefs about abilities or roles, biases regarding management, and inadequate resources.
• When conflict occurs, several strategies can help. Focus on what is right for the patient, not who is right; this includes focusing on interests, not positions, and on concerns and desired outcomes.
• Create options for mutual gain by brainstorming to yield win-win solutions and insist on the use of objective criteria provides the basis for further improvement.
• At a system level, a rapid response team can be created to assemble people with essential skills quickly to respond to emergencies.
• Early activation can improve outcomes and protocol should designate the roles of different team members.

Teamwork Tools

• Teamwork, like medical and technical skills, can be taught and learned.
• Important concepts and tools include situational awareness, standardized language, closed-loop communication, mutual respect, and a shared mental model.
• A standardized approach to teamwork tools should be supported at all levels of leadership.

Situational Awareness

• In an emergency, it is easy to fixate on one particular task and lose sight of the overall situation.
• Team members can help one another remain aware of active issues and potential complications by cross-monitoring.
• Early briefings followed by huddles when new issues arise can ensure that all team members have the same understanding of the situation.
• Situational monitoring is an important patient safety tool that facilitates situational awareness.
• The acronym STEP (Status of patient, Team members, Environment, Progress towards goal) can be used to remember important components of situational monitoring.

Standardized Language

• Inadequate communication at shift change can compromise patient safety.
• Call-outs inform all team members quickly when new critical events occur.
• SBAR (Situation, Background, Assessment, Recommendation) is a standard communication technique for conveying critical information.
• Use of SBAR in one institution resulted in a 72% to 88% improvement in updating patient medication lists on admission and a 53% to 89% improvement in having a corrected medication list on discharge.
• The rate of adverse events decreased from 89.9 per 1,000 patient days to 39.96 per 1,000 patient days.
• Effective patient handoffs should include interactive communications, limited interactions, a process for verification, and an opportunity to review relevant historical data.

Closed-Loop Communication

• Closed-loop communication means that the individual receiving a message confirms or repeats back what they have heard from the individual sending the message, so that they can affirm that the message is correct or offer a correction.
• This is a three-step process that ensures clarity and accountability.

Shared Mental Model

• Situational awareness, standardized language, and closed-loop communication can allow a team to have a shared mental model.
• Without a shared mental model, teamwork and patient safety can be compromised.

Mutual Respect

• The ability to communicate clearly and effectively is an essential element of teamwork.
• Intimidating and disruptive behavior undermine patient safety and should not be tolerated.
• The Two-Challenge Rule and CUS Words are two communication strategies designed to give voice to all team members.
• Two-Challenge Rule : allows a team member to clearly articulate a concern regarding a perceived or real patient safety breach.
• CUS Words: a communication strategy in which every individual in a care unit is trained to listen when the specific words are spoken: "I'm Concerned", "I'm Uncomfortable", "This is a Safety issue"

Briefings, Huddles, and Debriefings

• Briefings are held before any patient care episode to allow team members to review risk factors, designate roles, and ensure that everyone has a shared mental model regarding how to proceed.
• Huddles are brief gatherings of care team members to discuss patient status and the management plan when issues arise during patient care.
• Debriefings allow team members to learn from patient care episodes, regardless of the outcome.

Fatigue

• Fatigue can affect patient safety factors including memory, speed, and mood.
• On standardized testing, adults with fewer than 5 hours of sleep per night have difficulty with short-term memory, retention, and concentration.
• Resident work-hour requirements are an attempt to prevent fatigue-related medical errors.
• Individuals can ensure they are fit for work by reviewing the I'M SAFE (Illness, Medication, Stress, Alcohol and Drugs, Fatigue, Eating and Elimination) checklist.

Medication Errors

• On average, US patients experience one medication error per patient per hospitalization day.
• Electronic medical records (EMRs) are helpful in reducing errors due to poor legibility and can identify drug allergies and drug interactions.
• Prescribing errors can be reduced by avoiding nonstandard abbreviations and using the "always lead, never follow" rule of placing a zero before numbers lower than 1 and not placing a zero after a decimal point.
• Medication errors are common after transitions in care. These errors can be reduced through systematic, careful medication reconciliation on admission, transfer, and discharge.
• Distraction can lead to errors.
• Using closed-loop communication can be lifesaving.

Health Information Technology

• Health information technology (IT) can be a valuable patient-safety tool facilitating provider communication, tracking and reporting data, providing point-of-care reading material, promoting adherence to practice guidelines, and increasing patient engagement.
• For data to be useful, they must be interpreted and acted on appropriately.
• Larger databases can produce more powerful research and recommendations.

System-Level Change Versus Blaming Individuals

• Reducing medical errors to improve patient safety is a high priority.
• Traditionally, medical culture expects perfection, and the typical tactic to fix errors is to ascribe individual blame.
• Although there is a tendency to scapegoat an individual when things go wrong, there usually are numerous factors and system issues that lead to the adverse outcome.
• Examples of ways to effect change at a system level include using checklists and protocols, which have been documented to improve outcomes through standardization of practice.
• The aviation industry made minimal progress in safety and reliability until they developed a broader notion of safety and considered the multiplicity of factors underlying airplane crashes and pilot errors.

Community Birthing

• One area in which system-level interventions are needed to improve patient safety is community birthing, including home and free-standing birth center deliveries.
• Lack of role clarity and poor communication are the biggest predictors of preventable maternal and neonatal outcomes, including death.

Maternal Mortality

• Although maternal mortality has decreased in most low- and high-resource countries since the 1990 United Nations Millennium Development Goals were issued, it has increased in the United States.
• Reasons for the increase are complex and include many factors, one of which is improvements in reporting strategies.
• The increase in the US MMR is not only due to increased reporting, because some states had increases in MMR during periods when no changes were made to reporting systems.
• Defunding of pregnant people's health also has been associated with the increase in maternal mortality in certain states.
• Despite the increasing US MMR, California's ratio decreased from 21.5 to 15.1 between 2003 and 2014. Some have attributed the improved outcomes in California to systems changes introduced by the CMQCC patient safety bundles.

OB Readiness

• There is a large and growing number of "pregnancy care deserts" in the United States where there are few if any labor and delivery units.
• Maternal mortality is higher in rural than in urban areas.
• OB readiness is preparedness to provide antenatal, intrapartum, and postpartum services for normal and complicated deliveries that occur in Level 0 areas, which have fewer capabilities than a Level 1 facility.
• ALSO can improve OB readiness and outcomes.

Health Disparities

• From 2016 to 2018, the MMRs were 41.4 deaths per 100,000 live births among non-Hispanic Black pregnant people, 26.5 among non-Hispanic American Indian or Alaska Native pregnant people, 14.1 among non-Hispanic Asian or Pacific Islander pregnant people, 13.7 among non-Hispanic white pregnant people, and 11.2 among Hispanic pregnant people in the United States.
• It is estimated that medical care only accounts for 10% to 20% of modifiable contributors to health outcomes, and social determinants of health account for the other 80% to 90%.
• Racism, not race, is a major contributor to pregnancy care disparities.

Patient-Safety Bundles

• The Council on Patient Safety in Women's Health Care has developed patient-safety bundles through AIM.
• The safety bundles follow a 4-R structure: 1) Readiness, 2) Recognition and prevention, 3) Response, and 4) Reporting/systems learning.

Patient Safety and Malpractice Risk

• An additional anticipated benefit of a reduction in adverse obstetric outcomes is a decrease in malpractice loss for physicians and hospitals.
• Preventing medical errors is an important part of a multifaceted approach to resolving what is perceived as a current malpractice crisis.
• The cost of malpractice insurance can affect the ability to provide pregnancy care and the satisfaction of physicians who pay high insurance premiums.
• An unhappy patient usually is the trigger for a lawsuit.
• Malpractice litigation takes a significant toll on all individuals involved.
• The most common primary allegations of obstetric claims are a neurologically impaired infant (27.4%) and stillbirth or neonatal death (15%).
• Risk management is a strategy that attempts to prevent or minimize patient injuries, decrease the chance of successful malpractice litigation when an injury does occur, and reduce the amount of the award in a successful claim.

Malpractice Insurance Rates

• Professional liability insurance companies may offer discounts on medical malpractice premiums to pregnancy care provider clients who take the ALSO course or other pregnancy-care training designed to reduce liability

The Five Cs of Risk Management

• Compassion. Every lawsuit begins with a dissatisfied patient and/or family. Patients find it more difficult to sue someone they like and who they think cares about them.
• Communication. Spending more time with patients may result in fewer lawsuits. Patients who receive adequate explanations about their conditions and test results are more satisfied.
• Competence. Clinicians must know their own ability in any given situation.
• Charting. Many lawsuits are filed against pregnancy-care providers and lost because of inadequate documentation.
• Confession. Discussing mistakes with the patient has been actively discouraged in the past; however, many studies confirm that one of the more common reasons for filing a suit is a suspected cover-up.

Simulations

• Simulations can be used to practice the communication and teamwork concepts taught in this chapter in the context of managing obstetric emergencies.
• Simulations allow multidisciplinary teams to practice managing obstetric emergencies when patient lives are not at risk.
• With simulations, teams have a briefing to discuss roles before managing a labor. The team then manages an emergency. Finally, the team debriefs, focusing on what went well and why, what did not go well and why, and what can be done to make things better in the future.

Patient Safety in Low-Resource Settings

• In low-resource settings, teamwork and communication can save lives just as in higher-resource settings.
• System issues have a greater effect where there is a lack of infrastructure.
• Delays that lead to maternal morbidity and mortality can be categorized as those in 1) seeking medical care, 2) getting to a medical facility, and 3) receiving quality care after arriving at a medical facility.
• ALSO and BLSO are particularly effective in promoting patient safety in low-resource settings.

Summary

• Pregnant people and/or their infants die or experience permanent injury because of preventable errors.
• Routine use of briefings, huddles, and debriefings can help avoid communication errors, which account for more than 70% of medical errors.
• Teamwork tools include situational awareness, standardized language, closed-loop communication, and development of shared mental models.
• Tools such as the Two-Challenge Rule and CUS Words empower all individuals involved in patient care to speak up and influence care when they perceive that errors are occurring.
• ALSO mnemonics help team members approach the situation similarly when emergencies arise.
• Following the Five Cs can reduce the risk of malpractice litigation through improved patient care.
• ALSO simulations can be implemented to enhance team function for more effective management of obstetric emergencies.