Transcript The Role of Obstetrical Claims in Medical liability

The Role of Obstetrical Claims in
Medical liability
Alethia (Lee) Morgan, M.D. FACOG
Patient Safety and Risk Management
COPIC
Disclosure
I have no relevant financial
relationships to disclose
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What is in it for you today
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Impact of OB/GYN claims on medical liability
Impact medical liability rates on access to OB care
COPIC experience
Patient safety in OB
What specialty spends the highest
percentage of their annual net income
on PLI coverage?
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Pediatrics
Obstetrics/Gynecology
Orthopedic Surgery
Emergency Medicine
Neurosurgery
What specialty spends the highest
percentage of their annual net income
on PLI coverage?
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Pediatrics
Obstetrics/Gynecology
Orthopedic Surgery
Emergency Medicine
Neurosurgery
ACOG 2006 Professional Liability Survey
Liability Claims Experience
At least 1 claim filed against
respondents during their career
89.2%
Average number of claims filed
against all ’06 respondents
2.62%
At least 1 claim filed against
respondents during their residency
37.3%
ACOG 2006 Professional Liability Survey
Liability Claims Experience
1996
1999
2003
2006
At least 1 claim filed
during their career
73%
76.5%
76.3%
89.2%
Average number of claims
filed
2.31
2.53
2.64
2.62
27%
28.6%
29.6%
37.3%
At least 1 claim filed
during their residency
PIAA Data Sharing Project
• Who
• 21 US PLI companies
• What
• Collects data on closed claims-1985-2007
• When
• Puts out semi annual reports
• Why
• Provide statistical data re: PLI to members
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Indemnity payments by specialty
Ob/Gyn
• #1 for total claims reported
• #1 for percentage of paid claims/total claims
• 35.2%
• 5.7% more than any other specialty
• #1 for total indemnity paid
PIAA Data Sharing System Report 082
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Four top conditions/procedures for
number of paid claims
• Account for over $9 billion paid
• Over 35% of dollars paid out of top 40
1.
2.
3.
4.
Brain damaged infant
Breast cancer
Pregnancy
Acute myocardial infarction
PIAA Data Sharing System Report 082
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Four top conditions/procedures
for total indemnity dollars paid
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2.
3.
4.
Brain damaged baby
Breast cancer
Pregnancy
Symptoms of abdomen and pelvis
PIAA Data Sharing System Report 082
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COPIC data (15+YRS)
By Error/site type
• 49% conduct in L&D setting
• 26% conduct related to technical performance and
complications of GYN surgery
• 21% conduct related to diagnosis and treatment of
non-obstetrical conditions, usually in the office setting
• 5% conduct directly related to prenatal care
COPIC data (15+YRS)
49% conduct in L&D setting
• Neurologically impaired infants
• Improper interpretation of FHR tracing
• Failure to respond to abnormal FHR tracing in a timely
manner
• Complications of VBAC
• Complications of operative vaginal delivery
COPIC data (15+YRS)
26% conduct related to technical performance and
complications of GYN surgery
• Bowel / bladder/ureteral injury
• Sepsis/ post-op infection / abscess
• Unexpected/poor outcome
• Lack of adequate indication for elective surgery
COPIC data (15+YRS)
21% conduct related to diagnosis and treatment of
non-obstetrical conditions, usually in the office setting
• Delayed DX of cancer
Breast, Cervix, Ovary, Germ cell, Colon, Lung
• Delayed DX of MI, PE, Intracranial Tragedies
• Delayed DX of Severe Infectious Diseases
• Medication Errors
COPIC data (15+YRS)
5% conduct directly related to prenatal care
• antenatal DX of fetal abnormalities
• genetic screening
• group B strep
• prematurity management
The defense of L&D adverse outcomes often points to the
prenatal record
OB-GYN risks summarized
 Most claims involve elements of communication or
information breakdown
 Many claims could have a causation defense, but the
necessary elements were missing or not documented
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Prevention
 Standardized Communication
 Online EFM Course
 Team Training
 Disaster Training/Drills
 Simulation
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Defense
 ACOG neonatal encephalopathy
guidelines and suggestions
for practice
 Proper documentation
 Gather clinical evidence for timing
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COPIC patient safety initiatives
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OB Patient safety/RM seminar
Team work
Common language
Disaster drills
Simulation
Checklists
Standard orders
Checklists
• Monitoring
– oxytocin
– magnesium sulfate
– misoprostol
– Other high risk medications
• Documentation
– Shoulder dystocia
– Operative vaginal delivery
These are available at www.callcopic.com
What do the checklists do for us?
 Make explicit the minimum expected
steps in a complex system
 Help memory recall
 Provide a conservative, “default”
mode of management which will be
carried out in the absence of our
specific order to the contrary in a
specific patient.
 Used in this manner, it is much more
difficult for a patient to be injured by
these medications.
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Patient safety toolkit
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Keep the patient and family informed
Workup an unhealthy baby early
Document, Document, Document
Honest disclosure to patient and
family when problems occur
• Keep the lines of communication
open with patient and family before
and after discharge
The best way to prevent being sued
 Prevention of the problem from
occurring in the 1st place
 Thus patient safety is the lynchpin
of risk management
 But sometimes adverse outcomes
occur despite perfect care
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The Science
Officially endorsed by:
CDC
Child Neurology Society
March of Dimes
NICHD
Royal Australian and NZ
College of Ob/Gyn
SMFM
Society of Ob/Gyn of
Canada
January 2003
NNE
25% Antepartum and
intrapartum risks
4% Intrapartum hypoxia
only
69% Antepartum risks
2% No identified risk
factors
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Are Obstetricians an Endangered Species?
•There is currently no proven way to reduce the incidence
of cerebral palsy in most cases
•Obstetricians can expect to be sued approximately once
every 10 years
•Reimbursement is relatively fixed
•Practitioners are leaving early at one end of the pipeline,
and fewer students are entering training at the other end
Effects of Liability: Changes in Practice‡ Among
Respondents Who Have Practiced Obstetrics Between
1995 and 2006*
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Accepted fewer public aid patients:
Accepted fewer high-risk patients:
Performed more ultrasounds:
Performed more Cesarean sections:
Stopped performing VBACs:
Reduced salaries (of physicians/staff):
Delayed upgrading office equipment:
Stopped practicing obstetrics:
Stopped practicing obstetrics or
retired from practice:
182 (26%)
153(22%)
236 (33%)
203(29%)
187 (26%)
217 (31%)
145(20%)
99 (14%)
110 (15%)
‡ Changes specifically due to liability insurance costs or liability pressure
*N=711
CGOS 2006 survey data of OB providers in CO
Access to Obstetrical Care
Liability insurance premium increase
$0/yr
$5,000/yr
476 (100)
424 (89)
336 (71)
267 (56)
23 (36)
24 (38)
29 (45)
32 (50)
Number of births in counties without
obstetrical care providers, No. (%) ‡
1,783
(2.5)
1,902
(2.7)
2,988
(4.2)
3,808
(5.4)
Number of births in counties with limited
availability of obstetrical care providers,
No. (%) §
32,185
(45)
33,969
(48)
48,179
(68)
49,348
(70)
Providers continuing current obstetrical
practice, No. (%)
Number of counties without practicing
obstetrical care providers, No. (%)
$10,000/yr $15,000/yr
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Numbers and percentages are based on birth data collected for the year 2006 by the Colorado
Department of Public Health and Environment.
§ Counties with 16 or more births per month per obstetrical care provider.
CGOS 2006 survey data of OB providers in CO
Do Rising Costs Affect Access?
Attrition among current providers of OB care due to
increasing liabililty insurance premiums (2006 data)
100%
90%
80%
70%
60%
50%
40%
$0
$5,000
All Providers of OB Care (N=476)
$10,000
OB/GYNs Practicing OB (N=243)
$15,000
FP doing OB (N = 195)
CGOS 2006 survey data of OB providers in CO
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Thank you
“It has never been safer to have a baby
and never more dangerous to be an
obstetrician.”
Questions?
MacLennan et al: JAMA 2005;294:1688-1690
Alethia (Lee) Morgan, M.D.
[email protected]
www.callcopic.com
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2007
FP
$13,544
OB/Gyn $54,545
FP
$ 60,402
OB/Gyn $275,466
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