A Study of OB Claims

Society of OB/GYN
Hospitalists
September 24, 2011

Darrell Ranum, JD, CPHRM

Regional Vice President,
Patient Safety

Introduction
1. Introduction to Executive Information Systems
2. Overview of OB Closed Claim Study
a. Number of neonatal and maternal OB claims
b. OB claim frequency

3. Injury Severity
a. Neonatal injuries
b. Maternal injuries

4. Infant OB Claims
5. Maternal OB Claims
6. Discussion
OB Advisory Board / 2

Executive Information Systems

Developed by CRICO/Strategies, the Harvard
health care systems insurance captive and
RM program
Provides an extensive taxonomy for coding the
clinical aspects of medical malpractice cases
Todays studies include only closed claims

OB Advisory Board / 3

OB Patient Ages by Loss Year

Patients' Ages for Events Claim
2000-2010
Count
Unknown
30
Neonatal (< 1 month)
210
First Year (111 months)
1
Teenager (1017 years)
6
Young Adult (1829 years)
114
Adult (3064 years)
76
*TOTAL
437

Infant claims=211
Maternal claims=96
OB Advisory Board / 4

The Doctors Company OB/GYN

Claim Frequency by Report Year

OB Advisory Board / 5

OB Injury Severity
1. Neonatal claims comparing 20002004 with
20052009 time periods
a. NAIC severity index categories (low, medium,
and high)

2. Maternal claims comparing 20002004 with

20052009 time periods
a. NAIC severity index categories (low, medium,
and high)

OB Advisory Board / 6

Injury Severity for Neonatal Claims

OB Advisory Board / 7

Injury Severity for Maternal Claims

OB Advisory Board / 8

Moving Beyond the Numbers

1. Numbers are interesting but they do not tell
the stories of the cases they represent
2. We need to drill deeper to learn about the
underlying causes of patient harm
3. We can study these cases using a variety of
data points:

Allegations
Risk Management Issues ( Contributing factors )
Diagnoses
Procedures
And many more

OB Advisory Board / 9

Neonatal OB Claims

OB Advisory Board / 10

Neonatal OB Claims
1. Most common allegations
2. Most common risk management issues
(contributing factors)
3. Most common neonatal injuries
4. Neonatal injuries by allegation
5. Observations

OB Advisory Board / 11

Neonatal OB Allegations:
20002004 Versus 20052009

OB Advisory Board / 12

Neonatal OB RM Issues:
20002004 Versus 20052009

Note: Most claims have multiple Risk Management issues

OB Advisory Board / 13

Neonatal Injuries 20002009

About 20% of all claims result in indemnity

OB Advisory Board / 14

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 20052009 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

Neonatal Claims by Procedure

OB Advisory Board / 16

Neonatal Injuries (Organ Damage, Death,

and Nerve Damage) by Allegation

OB Advisory Board / 17

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

Observations in Neonatal Death

and Brain Damage Cases
Physicians postponed c-sections
Attempted other methodsvacuum delivery
Waited to see if symptoms improve

Physicians were slow to respond to calls

from nurses
Asked nurses to try more interventions
Physicians arrived later than requested

OB Advisory Board / 19

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

Observations in Neonatal Death

and Brain Damage Cases (continued)
Inexperienced nurses
Failed to recognize non-reassuring fetal heart
rate tracings
Delayed assessment of the patient at a critical time
Following a MVA
When admitted for preeclampsia

OB Advisory Board / 21

Observations in Neonatal Nerve

Damage Cases
Nerve damage case allegations
Improper choice of delivery method
Improper performance of delivery
Inadequate consent

OB Advisory Board / 22

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

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

Observations in Neonatal Nerve

Damage Cases (continued)
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 ready
to deliver

OB Advisory Board / 25

Process of Care Diagram

For Neonates

OB Advisory Board / 26

Process of Care Diagram

Look at labor and delivery from the
patients 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

OB Advisory Board / 28

Tools for Reducing Birth Injury Cases

Summary
Look for tools to stimulate discussion
Tools help physicians and staff look at system
issues 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 nurses

and physicians
Help them solve the system problems together

OB Advisory Board / 29

Maternal OB Claims

OB Advisory Board / 30

Maternal OB Claims
1. Most common allegations
2. Most common risk management issues
(contributing factors)
3. Most common maternal injuries
4. Maternal injuries by allegation
5. Maternal claims by procedure
6. Maternal procedures by risk management issue
7. Summary of maternal injury cases

OB Advisory Board / 31

Maternal Claims by Allegation

OB Advisory Board / 32

Maternal Claims by Risk Management Issue

OB Advisory Board / 33

Maternal Injuries 20002009

OB Advisory Board / 34

Maternal Injuries by Allegation

OB Advisory Board / 35

Maternal Claims by Procedure

OB Advisory Board / 36

Procedures by RM Issue

OB Advisory Board / 37

Examples of Maternal Injuries

1. Emotional trauma
2. Foreign body
3. Death

OB Advisory Board / 38

Maternal InjuriesEmotional Trauma

1. Infant death=13 of 15 cases
a. In one case the mother also experienced
HELLP syndrome

2. No consent for infant autopsy=one of 15 cases

3. No consent for circumcision=one of 15 cases

OB Advisory Board / 39

Maternal InjuryForeign Body

1. Sponge left following c-section=seven of
13 cases
2. Gauze pads left in vagina following vaginal
births=five of 13 cases
3. Fetal scalp electrode retained=one of 13 cases

OB Advisory Board / 40

Maternal InjuryDeath
1. Bleeding after delivery=three of six cases
2. 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

3. Arrested in hospital=one of six cases

Dehydration and electrolyte imbalance due to

undiagnosed diabetic ketoacidosis

4. Amniotic fluid embolism=one of six cases

Seizure during delivery

OB Advisory Board / 41

Maternal InjuriesHemorrhage
1. Continued bleeding after c-sections=three of
four cases
a. One case due to abnormal coagulation (studies
conducted after emergency hysterectomy)

2. Continued bleeding after vaginal delivery=one

of four cases
3. Plus three hemorrhages resulting in death
(slide 41)

OB Advisory Board / 42

Maternal OB Claim Observations

1. Most maternal injuries are emotional due to the
death or serious injury of their neonates
2. The majority of physical injuries to mothers are
not severe
a. Foreign bodies retained
b. Infections
c. Other complications of surgery

3. Injuries to mothers have the potential to

be catastrophic
a. Hemorrhage
b. Brain damage
c. Death
OB Advisory Board / 43

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

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

A Study of GYN Claims

Society of OB/GYN
Hospitalists
September 24, 2011

Darrell Ranum, JD, CPHRM

Regional Vice President,
Patient Safety

Introduction

Number of claims from 20012010=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

Introduction (continued)

Injury severity
Body part
Admitting diagnosis
Final diagnosis
Procedures
Observations

OB Advisory Board / 48

GYN Claims by Patient Age

OB Advisory Board / 49

GYN Patient Ages by Decade

OB Advisory Board / 50

Allegations Sub-CategoriesTop 3
1. Surgical treatment
1. Improper performance of surgery53%
2. Improper management of surgical patient7%
3. Retained foreign body6%

2. Diagnosis-related
1. Failure to diagnose8%
2. Delay in diagnosis5%

3. Medical treatment (non-OB)

1. Improper performance of treatment or procedure3%
2. Improper management of treatment course2%

OB Advisory Board / 51

Risk Management IssuesTop 6

Technical performance42%
Possible technical problem
Poor technique
Misidentification of anatomical structure

Patient assessment issues28%

Failure or delay ordering diagnostic test
Failure to establish a differential diagnosis
Failure to note clinical information

Patient factors24%
Seek other providers due to dissatisfaction
Patient non-compliance with follow-up call or appointment
Patient non-compliance with treatment regimen

OB Advisory Board / 52

Risk Management Issues

(continued)

Communication between patient/family and

providers19%
Inadequate consent for surgical procedure
Poor patient rapport

Selection and management of therapy15%

Selection of surgical procedures

Insufficient or lack of documentation10%

For informed consent
Re: clinical findings
Re: clinical rational

OB Advisory Board / 53

GYN Patient Injuries

Puncture/perforation19%
Death9%
Foreign body5%
Malignancy5%
Infection5%
Emotional trauma5%
Laceration/tear5%
Burn 4%
Fistula4%

OB Advisory Board / 54

GYN Patient Injury Severity

OB Advisory Board / 55

Procedures from Which the Injury Arises

OB Advisory Board / 56

Admitting DiagnosisTop 15

OB Advisory Board / 57

Final DiagnosisTop 10

OB Advisory Board / 58

Observations
1. The most common allegation Improper Performance
of Surgery (53% of GYN claims) is related to:

The most common RM issue, Technical Performance42%

The most common injurypuncture or perforation
The most common final diagnosis998.2 puncture/laceration
during procedure
Other surgical issues include:

Improper management of surgical patientidentifying and

responding to post-op complications
Retained foreign body

OB Advisory Board / 59

Observations (continued)
2. Diagnosis-related allegations (15% of GYN claims)
are associated with the second most common
contributing factor, patient assessment issues

Failure to order diagnostic test

Failure to establish a differential diagnosis
Failure to note clinical information

OB Advisory Board / 60

Observations (continued)
3. Some claims arise from failures in communication
between patient/family and providersthe fourth
most common RM issue19%

Patients seek other providers due to dissatisfaction

Inadequate consent for surgical procedure
Poor patient rapport
A review of case abstracts reveals that language barriers
are often a contributing factor to errors or to
misunderstandings between physician and patient

OB Advisory Board / 61

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 / 62