A Study of OB Claims Society of OB/GYN Hospitalists September 24, 2011

1. A Study of OB ClaimsSociety of OB/GYN Hospitalists September 24, 2011 Darrell Ranum, JD, CPHRM Regional Vice President, Patient Safety

2. Introduction • Introduction to Executive Information Systems • Overview of OB Closed Claim Study • Number of neonatal and maternal OB claims • OB claim frequency • Injury Severity • Neonatal injuries • Maternal injuries • Infant OB Claims • Maternal OB Claims • Discussion OB Advisory Board / 2

3. Executive Information Systems • Developed by CRICO/Strategies, the Harvard health care system’s insurance captive and RM program • Provides an extensive taxonomy for coding the clinical aspects of medical malpractice cases • Today’s studies include only closed claims OB Advisory Board / 3

4. OB Patient Ages by Loss Year Patients' Ages for Events Claim 2000-2010 Count Unknown 30 Neonatal (< 1 month) 210 First Year (1–11 months) 1 Teenager (10–17 years) 6 Young Adult (18–29 years) 114 Adult (30–64 years) 76 *TOTAL 437 Infant claims=211 Maternal claims=96 OB Advisory Board / 4

5. The Doctors Company OB/GYN Claim Frequency by Report Year OB Advisory Board / 5

6. OB Injury Severity • Neonatal claims comparing 2000–2004 with 2005–2009 time periods • NAIC severity index categories (low, medium,and high) • Maternal claims comparing 2000–2004 with 2005–2009 time periods • NAIC severity index categories (low, medium,and high) OB Advisory Board / 6

7. Injury Severity for Neonatal Claims OB Advisory Board / 7

8. Injury Severity for Maternal Claims OB Advisory Board / 8

9. Moving Beyond the Numbers • Numbers are interesting but they do not tell the stories of the cases they represent • We need to drill deeper to learn about the underlying causes of patient harm • We can study these cases using a variety ofdata points: • Allegations • Risk Management Issues ( Contributing factors ) • Diagnoses • Procedures • And many more OB Advisory Board / 9

10. Neonatal OB Claims OB Advisory Board / 10

11. Neonatal OB Claims • Most common allegations • Most common risk management issues (contributing factors) • Most common neonatal injuries • Neonatal injuries by allegation • Observations OB Advisory Board / 11

12. Neonatal OB Allegations: 2000–2004 Versus 2005–2009 OB Advisory Board / 12

13. Neonatal OB RM Issues:2000–2004 Versus 2005–2009 Note: Most claims have multiple Risk Management issues OB Advisory Board / 13

14. Neonatal Injuries 2000–2009 About 20% of all claims result in indemnity OB Advisory Board / 14

15. Observations Regarding Neonatal Claims • The top three patient injuries make up about 86 percent of all injuries (see slide 14) • The six most common risk management issues are seen less frequently as a contributing factor in the 2005–2009 time frame (see slide 13) • The percentage of high severity patient injuries is slightly lower in recent years (see slide 7) • Claim frequency (number of claims) is lower (see slide 5) OB Advisory Board / 15

16. Neonatal Claims by Procedure OB Advisory Board / 16

17. Neonatal Injuries (Organ Damage, Death, and Nerve Damage) by Allegation OB Advisory Board / 17

18. Infant Brain Damage and Death Cases • In half of neonatal brain damage and death cases, Delay in Treatment of Fetal Distress was the major allegation. • Why? OB Advisory Board / 18

19. Observations in Neonatal Death and Brain Damage Cases Physicians postponed c-sections Attempted other methods–vacuum delivery Waited to see if symptoms improve Physicians were slow to respond to callsfrom nurses Asked nurses to try more interventions Physicians arrived later than requested OB Advisory Board / 19

20. Observations in Neonatal Death and Brain Damage Cases (continued) Communications failed at critical times Nurse notified physician of decelerations, physician expected nurse to call again if no improvement. Nurse expected physician to come to the hospital. Nurse communicated information about fetal distress. Physician did not recognize the urgency of the situation/denies receiving info OB Advisory Board / 20

21. Observations in Neonatal Death and Brain Damage Cases (continued) Inexperienced nurses Failed to recognize non-reassuring fetal heartrate tracings Delayed assessment of the patient at a critical time Following a MVA When admitted for preeclampsia OB Advisory Board / 21

22. Observations in Neonatal NerveDamage Cases Nerve damage case allegations Improper choice of delivery method Improper performance of delivery Inadequate consent OB Advisory Board / 22

23. Observations in Neonatal Nerve Damage Cases(continued) Managing the pregnancy leading up to labor and failure to address: History of large babies or obese mothers and failure to adequately assess sizes of fetuses History of gestational diabetes, but no documentation of GTT History of shoulder dystocia, but no discussion of risks of vaginal deliveries or C-section options Allowing more than one week post dates for suspected large infants OB Advisory Board / 23

24. Observations in Neonatal Nerve Damage Cases(continued) Management of labor and technique Allowed prolonged labor with large infants Multiple attempts of vacuum extraction with failure to progress Alleged improper technique for addressing shoulder dystocia Documentation indicating fundal pressure rather than suprapubic pressure OB Advisory Board / 24

25. Behaviors of mothers Non-compliant with diabetic diets Refused to consider c-sections, even with prolonged second stage of labor or other risk factors Delayed arriving at the hospital until almost readyto deliver Observations in Neonatal Nerve Damage Cases(continued) OB Advisory Board / 25

26. Process of Care Diagram For Neonates OB Advisory Board / 26

27. Process of Care Diagram Look at labor and delivery from thepatient’s perspective The process of care is represented in a diagram The diagram incorporates all of the neonatal OB cases in the study Use the diagram to overlay your processes Could your processes potentially fail? Do your processes have the same weaknesses as the cases in the diagram? OB Advisory Board / 27

28. OB Advisory Board / 28

29. Tools for Reducing Birth Injury Cases Summary Look for tools to stimulate discussion Tools help physicians and staff look at systemissues objectively No guilt related to the cases in the diagrams No one needs to be defensive because these are not their cases Discussions foster collaboration between nursesand physicians Help them solve the system problems together OB Advisory Board / 29

30. Maternal OB Claims OB Advisory Board / 30

31. Maternal OB Claims • Most common allegations • Most common risk management issues (contributing factors) • Most common maternal injuries • Maternal injuries by allegation • Maternal claims by procedure • Maternal procedures by risk management issue • Summary of maternal injury cases OB Advisory Board / 31

32. Maternal Claims by Allegation OB Advisory Board / 32

33. Maternal Claims by Risk Management Issue OB Advisory Board / 33

34. Maternal Injuries 2000–2009 OB Advisory Board / 34

35. Maternal Injuries by Allegation OB Advisory Board / 35

36. Maternal Claims by Procedure OB Advisory Board / 36

37. Procedures by RM Issue OB Advisory Board / 37

38. Examples of Maternal Injuries • Emotional trauma • Foreign body • Death OB Advisory Board / 38

39. Maternal Injuries–Emotional Trauma • Infant death=13 of 15 cases • In one case the mother also experiencedHELLP syndrome • No consent for infant autopsy=one of 15 cases • No consent for circumcision=one of 15 cases OB Advisory Board / 39

40. Maternal Injury–Foreign Body • Sponge left following c-section=seven of 13 cases • Gauze pads left in vagina following vaginal births=five of 13 cases • Fetal scalp electrode retained=one of 13 cases OB Advisory Board / 40

41. Maternal Injury–Death • Bleeding after delivery=three of six cases • Arrested at home before labor=one of six cases • Undiagnosed pre-eclampsia or pulmonary edema which is more indicative of arrhythmia development and arrest than pre-eclampsia • Arrested in hospital=one of six cases • Dehydration and electrolyte imbalance due to undiagnosed diabetic ketoacidosis • Amniotic fluid embolism=one of six cases • Seizure during delivery OB Advisory Board / 41

42. Maternal Injuries–Hemorrhage • Continued bleeding after c-sections=three offour cases • One case due to abnormal coagulation (studies conducted after emergency hysterectomy) • Continued bleeding after vaginal delivery=one of four cases • Plus three hemorrhages resulting in death(slide 41) OB Advisory Board / 42

43. Maternal OB Claim Observations • Most maternal injuries are emotional due to the death or serious injury of their neonates • The majority of physical injuries to mothers are not severe a. Foreign bodies retained b. Infections c. Other complications of surgery • Injuries to mothers have the potential to be catastrophic a. Hemorrhage b. Brain damage c. Death OB Advisory Board / 43

44. Questions/Discussion: • Is your experience consistent with this data? • If not, what patient injuries are you seeing? • What are your priorities for improving patient safety? OB Advisory Board / 44

45. The Doctors Company dranum@thedoctors.com 1-800-421-2368, ext. 5186 • Our Mission is to advance, protect, and reward the practice of good medicine. OB Advisory Board / 45

46. A Study of GYN ClaimsSociety of OB/GYN Hospitalists September 24, 2011 Darrell Ranum, JD, CPHRM Regional Vice President, Patient Safety

47. Introduction • Number of claims from 2001–2010=370 • Claims by patient age • Most common allegations • Most common risk management issues (factors contributing to patient injury) • Types of injuries OB Advisory Board / 47

48. Introduction (continued) • Injury severity • Body part • Admitting diagnosis • Final diagnosis • Procedures • Observations OB Advisory Board / 48

49. GYN Claims by Patient Age OB Advisory Board / 49

50. GYN Patient Ages by Decade OB Advisory Board / 50