By Jacqueline Ross, RN, PhD, Shelise Valentine, RNC, MSN
Rates for maternal morbidity and mortality are higher in the U.S. than in any other developed country—and many of the harms suffered by patients are preventable. Analyzing medical malpractice claims that arise out of recurring, preventable sources of risk can aid medical professionals and institutions in identifying and adhering to best practices for care.
Study Design
This multifactorial study investigated postpartum claims to develop clinical recommendations to decrease the risks of postpartum morbidity and mortality.
Investigators reviewed 43 closed postpartum medical malpractice claims dating to incidents from 2015 to 2020, with the postpartum period defined as birth through 90 days post-discharge. Data was extracted using the Candello Comprehensive Risk Intelligence Tool (CRIT) and Advanced Report Writer (ARW) tool.
Researchers investigated factors present in postpartum claims, indicators of severe maternal morbidity (SMM), and socioeconomic factors.
Results
More than half of the claims studied were determined to have been preventable. Common themes emerged, including:
- Blood Transfusions: Blood product transfusion was the top SMM indicator among the studied claims. Our analysis found the need for facilities to have and follow blood transfusion guidelines, as many of the patients in these claims did not receive adequate blood products.
- Obstetric Hemorrhage: Obstetric hemorrhage was found to be a common indicator of SMM. Uterine atony accounts for 70 to 80 percent of obstetric hemorrhage, and if uterine atony is identified early, then it can be treated with medication (oxytocin) or fundal massage.
- Clinical Judgment: Clinical judgment was the contributing factor most frequently involved, appearing in 87 percent of the claims studied.
- Delays and Communication Gaps: Delay in treating hemorrhage was often accompanied by poor communication among members of the care team, who missed opportunities to use communication tools like Situation-Background-Assessment-Recommendation (SBAR).
- Socioeconomic Distinctions: Patient harms were unevenly distributed. Limits on information available regarding the patients in closed malpractice claims, together with the smaller scale of this data set, preclude any definitive stratification of patients’ risks. Nevertheless, the authors observe that higher-severity injuries tended to cluster among patients of color and patients with public health insurance or no health insurance.
- Care Bundles: One evidence-based method to improve the process of care and patient outcomes is the use of national patient safety bundles, which are structured and specific to clinical conditions, such as obstetric hemorrhage or severe hypertension in pregnancy.
Conclusion
Maternal injuries involve high severity in both patient impact and monetary impact. With its mission to advance, protect, and reward the practice of good medicine, The Doctors Company analyzes malpractice claims to better appreciate what motivates patients and their families to pursue claims and to gain a broader overview of system failures and processes that result in patient harm. Malpractice claims provide a retrospective review of care, and it is hopeful that information gained from claims can be used to design risk mitigation strategies to improve patient safety and reduce malpractice risk.
Jacqueline Ross, RN, PhD, is Coding Director, Department of Patient Safety and Risk Management, The Doctors Company, Part of TDC Group, and Shelise Valentine, RNC, MSN, is Director of Clinical Education, Healthcare Risk Advisors, Part of TDC Group
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.