Litigation in Obstetrics and Gynaecology:“Situational Awareness” and “Root Cause
Analysis”
Professor Dilly OC Anumba, LLM (Medical Laws)Academic Unit of Reproductive & Developmental MedicineDepartment of Human MetabolismUniversity of SheffieldSheffield
Outline• The economic and medicolegal burden of
litigation in Obstetrics and Gynaecology• Trends in litigation• “Situational awareness” - prevention• “Root Cause Analysis”- reflection/prevention • Any evidence that risk management works?• Future trends
Pattern of Obstetric and Gynaecologic Litigation
Litigation trends and incidence• Maternity claims - highest
value and second highest number of clinical negligence claims reported to the NHS Litigation Authority (NHSLA)
• Between 1st April 2000 and 31st March 2010– 5,087 maternity claims– Total value of claims £3.1
billion. – For 5.5 million births in
England, < 0.1% subject of a claim
Total number and value of maternity claims by financial year as at 31st March 2010
2000/2001
2001/2002
2002/2003
2003/2004
2004/2005
2005/2006
2006/2007
2007/2008
2008/2009
2009/2010
£0
£50,000,000
£100,000,000
£150,000,000
£200,000,000
£250,000,000
£300,000,000
£350,000,000
£400,000,000
£450,000,000
£500,000,000
0
100
200
300
400
500
600
700
800
Number of claims
Total value
• For settled maternity claims, average time from incident to claim resolution - 4.32 years.
• For claims with damages above £1 million, average time from incident to resolution - 8.57 years, usually more complex cases.
Claim categories• Three most frequent categories of claim:– management of labour (14.05%)– caesarean section (13.24%) – cerebral palsy (10.65%).
• Cerebral palsy and management of labour, including CTG interpretation, accounted for 70% of total value of all maternity claims
Practitioner experiencesAlderman B Litigation in obstetrics and gynaecology has increased in Merseyside. BMJ 1997; 314 doi: http://dx.doi.org/10.1136/bmj.314.7080.607 (Published 22 February 1997) Cite this as: BMJ 1997;314:607.1
• From 1 Jan to 31 Dec 1995 I spent 110.5 hours of time dealing with litigation issues (correspondence, reports to solicitors, interviews, etc) - about 3 working weeks. The majority of time in the evenings and weekends, not paid for by the NHS.
• If all 5 consultants spent roughly equivalent time dealing with their own litigation cases this would amount to about 550 consultant hours a year in department alone-equivalent to 16 working weeks of consultant time a year.
Practitioner experiences
Litigation in Department• January 1995 -106 cases• January 1996 - 146 cases, an increase of 38%.• Support staff spend time and huge effort in managing
complaints and litigation. Cost to taxpayers massive.• Full time risk management and legal teams
DEALING WITH THE LITIGATION BLACK HOLE THROUGH SITUATIONAL AWARENESS AND ROOT CAUSE ANALYSIS
Situational awareness• Definition: “the perception of elements in the
environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future.”– Assess and become aware of relevant factors in the
current environment– Consider any implications of these factors– Foresee future consequences
• “Knowing what is going on around you”.
Aviation example• Aviation industry• Highly reliable• Enviable record of safety– standardisation of process– unfailing use of checklist-driven protocols to govern
behaviour in high-risk situations– Crew resource management
• National Transportation Safety Board Press release SB-05-09. Washington (DC): March 29, 2005.• Degani Cockpit checklists: Concepts, design and use. Hum Factors1993;35:28-43.
Elements of a clinical• Patient is part of the environment• Environment is the setting• Task is the clinical encounter the treatment• Time is the context in which the treatment is to be
meted out.
The clinical situation elements
Loss of situational awareness
• Loss of sight of the bigger picture– Personae involved became highly focussed on
repeated attempts of a procedure
The Process of Situational Awareness and Assessment
Situational awareness activities
• Get information• Understand information• Think ahead
Comprehend or assign meaning to information• Compare • Critique• Diagnose
Maintaining Situational awareness
• The key is concentration• Discover and Recover– Discover potential situational awareness loss,
and recover it by getting more information, understanding it, and thinking ahead
• Communication
Situation, Background, Assessment, Recommendation (SBAR)
Description • SBAR provides a structured method
for communicating critical information about patients.
Benefits n Contributes to effective escalation of intervention in patient care. n Increases patient safety.
Situation, Background, Assessment, Recommendation (SBAR)
n Enhances handovers n Can be used for urgent and non-urgent communication
Situation, Background, Assessment, Recommendation (SBAR)
How is it used? • SBAR used to clarify information
that needs to be communicated between health care professionals by using easy-to-remember mechanism that is used to frame the conversation
Situation, Background, Assessment, Recommendation (SBAR)
Health care professionals structure their conversation around: • S - the situation of concern/discussion • B - the background of the
client/patient under review • A - an assessment of the
client’s/patient’s condition • R - the recommendations for
immediate and future care.
Situation, Background, Assessment, Recommendation (SBAR)
Tips for use n Consult widely with staff to gain co-operation to use the tool. n Use SBAR stickers to act as prompts. n Structure the ward documentation around the SBAR model. n Structure the handovers around the SBAR model. n Ensure SBAR is incorporated in teaching sessions and educational programmes/training. n Ensure SBAR is incorporated into the communication/operations policy/strategy.
SBAR Tools for clinical care
What is Root Cause Analysis? (RCA)• Process for identifying contributing/ causal
factors that underlie variations in performance associated with adverse events or close calls
• Process that features interdisciplinary involvement of those closest to and/or most knowledgeable about the situation
RCA Goals
• Find out:– What happened?– Why did it happen?– What do you do to prevent it from happening
again?– How do we know we made a difference?
• For details see either: http://vaww.ncps.med.va.gov/RCAtrain.htmlhttp://www.patientsafety.gov/tools.html
RCA Model• Focuses on prevention, not blame or
punishment (cornerstone: no one comes to work to make a mistake or hurt someone)
• Focuses on system level vulnerabilities rather than individual performance
- Communication - Environment/Equipment - Training - Rules/Policies/Procedures - Fatigue/Scheduling - Barriers
Overview of Steps• Set up inter-disciplinary team (4-6 people)– Those familiar and un-familiar with the process
• Flow diagram of “what happened?”– Triggering questions to expand this view– Site visits and simulation to augment– Interviews with those involved or those with similar job
• Resources • Root cause/contributing factors developed– Five rules of causation to guide/push the team deep enough– Cause and Effect Diagram, etc
RCA Contributory factors frameworkPatient Factors
Clinical condition
Physical Factors
Social Factors
Mental/Psychological
Factors
Interpersonal relationships
Staff Factors
Physical issues
Psychological Issues
Social Domestic
Personality Issues
Cognitive factors
Task Factors
Guidelines, Policies and Procedures
Decision making aids
Procedural or Task Design
RCA Contributory factors framework
Equipment
Displays
Integrity
Positioning
Usability
Work Environment
Administrative factors
Design of physical environment
Environment
Staffing
Work load and hours of work
Time
Communication
Verbal communication
Written communication
Non verbal communication
Communication Management
RCA Contributory factors frameworkOrganisational
Organisational structure
Priorities
Externally imported risks
Safety culture
Education and Training
Competence
Supervision
Availability / accessibility
Appropriateness
Team Factors
Role Congruence
Leadership
Support and cultural factors
EVIDENCE FOR EFFECTIVENESS OF RISK MANAGEMENT STRATEGIES
Interventions associated with• Improved perinatal outcomes• Reduced primary caesarean delivery rate• lower maternal and fetal injury• Reduced litigation– halving of the number of claims– 5-fold reduction in the cost of claims
• Clark AJOG 2008;199:105.e1-105.e7.
Key interventions in Clark et al 2008
• Rigorous guidelines that demonstrate Situation Awareness and SBAR
• External peer review akin to Root Cause Analysis
Conclusion• Better patient safety will hinge on
improvements in the quality of care, enhanced by best practice in Situational Awareness and Root Cause Analysis, in a cycles of service improvement that inevitably lead to reductions in the burden of litigation
