Checks and balances of team approach can stem errors in labor and delivery: behavioral interventions studied

OB/GYN News,  Oct 15, 2003  

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SAN FRANCISCO -- Mistakes happen. Individuals aren't perfect. That's why obstetricians need to foster a well-functioning labor and delivery team and emphasize systemic checks and balances, Dr. Paul G. Preston said.

A pilot program of behavioral interventions targeted at labor and delivery teams in four hospitals run by Kaiser Permanente Northern California recognizes that 95% of mistakes are made by good practitioners, not "bad apples," he said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

"Often what we know we should do is not what happens. That's why this is a behavioral approach," Dr. Preston said. More than 60% of medical errors derive from flaws in the system of care and the ways that caregivers interact and communicate with each other. Several behavioral interventions are being investigated in the pilot program to correct such errors, and researchers will measure whether they affect birth outcomes, staff attitudes, retention of nurses, patient satisfaction, and medicolegal claims. Results should be available next year, said Dr. Preston of the university and Kaiser Permanente.

In the study an insurance consultant analyzed 10 years of data from perinatal mistakes made at 250 Kaiser hospitals. The consultant identified recurring clinical and organizational problems that led to these mistakes. There were repeated problems with communication; team culture, such as who is allowed to say what and when; lack of information; and inadequate shift reports, "sign-outs," and handoffs.

A few clinical mistakes were linked to more than 80% of malpractice awards in lawsuits involving perinatal problems. "These are the dragons: You have got to recognize and respond to fetal distress. If you've got distress, you better be able to do a cesarean birth pretty quickly. You better be able to resuscitate a depressed infant. Be careful with Pitocin and be careful with instrumental deliveries," Dr. Preston said.

Borrowing a tactic from other industries, such as airlines, Kaiser decided to make improvements in teamwork. Commercial airplane pilots make from one to two mistakes per flight segment, but teamwork keeps most planes from crashing. "Individuals almost never do as well as a team," he said.

A 60-item questionnaire about safety attitudes administered to multidisciplinary teams at the four hospitals suggested that employees perceived better levels of safety and job satisfaction but worse teamwork and communication, compared with previous results from other hospitals.

To improve teamwork and communication, the program uses "situational briefs" to convey changes in a patient's condition in a direct and focused manner. The speaker quickly describes the situation, some background, his or her assessment of what's needed, and a recommendation for action. "This is especially helpful when you get a call at 2 a.m.," he said.

The teams must develop a climate in which it's OK for the speaker to recommend that the physician come to a patient's bedside quickly or recommend any other action.

The program also employs assertiveness training so that individuals speak up and state information persistently until the problem, a proposed action, and a decision are understood by all parties. In cases in which errors occurred, concern was usually expressed, the problem was stated (although often not clearly), the proposed action didn't happen, and a decision wasn't reached.

The multidisciplinary teams also conduct regular practice sessions in managing crises that are videotaped and discussed and then erased. The bulk of the debriefing focuses on assessing teamwork, communication, assertion, briefings, and detection of errors. Less time is devoted to technical issues.

Briefings before and after procedures, prospective care planning by the teams, and multidisciplinary rounds have been instituted as well. Scheduled social events should help team members get to know the people they work with, he noted.

ARTICLES BY SHERRY BOSCHERT San Francisco Bureau

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