An analysis of closed medical litigations against the obstetrics departments in Taiwan from 2003 to 2012†.

OBJECTIVE: To examine the epidemiologic data of closed medical claims from Taiwanese civil courts against obstetric departments and identify high-risk diseases. DESIGN: A retrospective descriptive study. SETTING/STUDY PARTICIPANTS: The verdicts from the national database of the Taiwan judicial system that pertained to obstetric departments were reviewed. Between 2003 and 2012, a total of 79 closed medical claims were included. MAIN OUTCOME MEASURES: The epidemiologic data of litigations including the results of adjudication and the disease and outcome of the alleged injury. RESULTS: A majority of the disputes (65.9%) were fetus-related. Four disease categories accounted for 78.5% of all claims including (i) perinatal maternal complications (25.3%); (ii) errors in antenatal screening or ultrasound diagnoses (21.5%); (iii) fetal hypoxemic-ischemia encephalopathy (16.5%); and (iv) brachial plexus injury (15.2%). Six cases (7.6%) resulted in an indemnity payment with a mean amount of $109 205. Fifty-one cases (64.6%) were closed in the district court. The mean incident-to-litigation closure time was 52.9 ± 29.3 months. All cases with indemnity payments were deemed negligent or were at least determined to be controversial by a medical appraisal, while all defendants whose care was judged as appropriate by a medical appraisal won their lawsuits. CONCLUSIONS: Almost 93% of clinicians win their cases but spend 4.5 years waiting for final adjudication. The court ruled against the clinician only if there was no appropriate response during a complication or if there was no follow-up or further testing for potential critical diseases.

A comprehensive obstetric patient safety program reduces liability claims and payments.

Begun in 2003, the Yale-New Haven Hospital comprehensive obstetric safety program consisted of measures to standardize care, improve teamwork and communication, and optimize oversight and quality review. Prior publications have demonstrated improvements in adverse outcomes and safety culture associated with this program. In this analysis, we aimed to assess the impact of this program on liability claims and payments at a single institution. We reviewed liability claims at a single, tertiary-care, teaching hospital for two 5-year periods (1998-2002 and 2003-2007), before and after implementing the safety program. Connecticut statute of limitations for professional malpractice is 36 months from injury. Claims/events were classified by event-year and payments were adjusted for inflation. We analyzed data for trends as well as differences between periods before and after implementation. Forty-four claims were filed during the 10-year study period. Annual cases per 1000 deliveries decreased significantly over the study period (P < .01). Claims (30 vs 14) and payments ($50.7 million vs $2.9 million) decreased in the 5-years after program inception. Compared with before program inception, median annual claims dropped from 1.31 to 0.64 (P = .02), and median annual payments per 1000 deliveries decreased from $1,141,638 to $63,470 (P < .01). Even estimating the monetary awards for the 2 remaining open cases using the median payments for the surrounding 5 years, a reduction in the median monetary amount per case resulting in payment to the claimant was also statistically significant ($632,262 vs $216,815, P = .046). In contrast, the Connecticut insurance market experienced a stable number of claims and markedly increased cost per claim during the same period. We conclude that an obstetric safety initiative can improve liability claims exposure and reduce liability payments.

A nationwide descriptive study of obstetric claims for compensation in Norway.

OBJECTIVE: To describe causes of substandard care in obstetric compensation claims. DESIGN AND SETTING: A nationwide descriptive study in Norway. POPULATION: All obstetric patients who believed themselves inflicted with injuries by the Health Service and applying for compensation. METHODS: Data were collected from 871 claims to The Norwegian System of Compensation to Patients during 1994-2008, of which 278 were awarded compensation. MAIN OUTCOME MEASURES: Type of injury and cause of substandard care. RESULTS: Of 871 cases, 278 (31.9%) resulted in compensation. Of those, asphyxia was the most common type of injury to the child (83.4%). Anal sphincter tear (29.9%) and infection (23.0%) were the most common types of injury to the mother. Human error, both by midwives (37.1% of all cases given compensation) and obstetricians (51.2%), was an important contributing factor in inadequate obstetric care. Neglecting signs of fetal distress (28.1%), more competent health workers not being called when appropriate (26.3%) and inadequate fetal monitoring (17.3%) were often observed. System errors such as time conflicts, neglecting written guidelines and poor organization of the department were infrequent causes of injury (8.3%). CONCLUSIONS: Fetal asphyxia is the most common reason for compensation, resulting in large financial expenses to society. Human error contributes to inadequate health care in 92% of obstetric compensation claims, although underlying system errors may also be present.

Understanding how attitudes affect physician compliance with legal behavioral constraints.

The following study investigates how physicians in one state (Illinois) attitudinally cope with a recent law mandating physician behaviors. Specifically, this study focuses on OB/GYN physician compliance with The Sexual Assault Survivors Emergency Treatment Act (Public Law 92-156, 2002), which requires hospitals in the state of Illinois to have an approved plan for treating sexual assault survivors. What makes this research setting interesting are the potential linkages between the legal mandate, physician attitudes, and the ongoing controversy concerning abortion. The results of a census of OB/GYN physicians within the state suggest (1) this physician group is largely supportive of the letter and spirit of this law, (2) the emerging attitude models such as Perugini and Bagozzi's (2001) MGB model explaining the formation of behavioral intentions must be treated with caution when generalizing to situations mandating legal behaviors, and (3) moderating influences such as attitude strength and religiosity have no apparent effect in how attitudes relate to physician motivation to comply with such laws. The managerial and research implications of the reported study are presented and discussed.

Business and Organizational Models of Obstetric and Gynecologic Hospitalist Groups.

The growth of obstetric and gynecologic (OB/GYN) hospitalists throughout the United States has led to different organizational approaches, depending on the perception of what an OB/GYN hospitalist is. There are advantages of OB/GYN hospitalist practices; however, practitioners who do this as just 1 piece of their practice are not fulfilling the promise of what this new specialty can deliver. Because those with office practices have their own business models, this article is devoted to the organizational and business models of OB/GYN hospitalists for physicians whose practice is devoted to inpatient obstetrics with or without emergency room and/or inpatient gynecology coverage.

The medical and economic impact of the Newborns' and Mothers' Health Protection Act.

OBJECTIVE: We evaluated the effect of the Newborns' and Mothers' Health Protection Act on clinical and cost outcomes. METHODS: We conducted an observational study of 18,023 healthy, mother-infant dyads before (n = 8670) and after (n = 9353) implementation of the Newborns' and Mothers' Health Protection Act legislation. Logistic regression was used to calculate adjusted odds ratios (ORs) for the following outcome measures: length of stay at least 48 hours, satisfaction with maternal length of stay, 7- and 30-day hospital readmission utilization, and 7- and 30-day emergency room utilization. Analysis of covariance was used to evaluate adjusted mean hospitalization costs per delivery. RESULTS: Mothers in the postlegislation period were more likely to have hospital stays at least 48 hours (OR 3.99; 95% confidence interval [CI] 3.57, 4.44) and rate their length of stay as "about right" (OR 5.54; 95% CI 4.76, 6.46) compared with mothers in the prelegislation period. Neonates in the postlegislation period were more likely to have hospital stays of at least 48 hours (OR 3.96; 95% CI 3.54, 4.43) and less likely to be rehospitalized within 7 days after hospitalization (OR 0.61; 95% CI 0.40, 0.95) compared with neonates in the prelegislation period. Adjusted mean hospitalization costs increased $116 per delivery in the postlegislation period. CONCLUSIONS: After implementation of the Newborns' and Mothers' Health Protection Act legislation, maternal and newborn length of stay and maternal satisfaction with length of stay increased substantially, and hospitalization costs increased significantly. The strongest clinical benefit was observed among neonates who were at a lower risk for hospitalization within 1 week of discharge. With the exception of 30-day emergency room utilization, there was insufficient statistical power to test for differences among other maternal clinical outcomes.

Pennsylvania's early discharge legislation: effect on maternity and infant lengths of stay and hospital charges in Philadelphia.

OBJECTIVE: To assess the effect of maternal length of stay (LOS) legislation on LOS and hospital charges associated with Philadelphia resident live births from 1994 through 1997. DATA SOURCE/STUDY SETTING: This was a descriptive epidemiological study involving secondary data analyses of linked birth record and hospital discharge data pertaining to all Philadelphia resident live births occurring between January 1, 1994 and December 31, 1997. STUDY DESIGN: Using these linked data, trends in median and mean maternal and infant LOS and hospital charges were described for three distinct time periods: (1) a "prelegislative" period (January 1, 1994 through June 30, 1995); (2) a one-year period during which LOS legislation was introduced, debated, modified, and eventually passed by Pennsylvania lawmakers (July 1, 1995 through June 30, 1996); and (3) a "post-LOS law" period immediately following enactment of Act 85 mandating minimum LOS for mothers and their newborns (July 1, 1996 through December 31, 1997). LOS variables for both mothers and infants were calculated based on the actual number of hours elapsing between birth and discharge; hospital charges were obtained directly from information available in the Hospital Discharge Survey data. PRINCIPAL FINDINGS: Maternal median charges and LOS per delivery for vaginal births rose from 5,270 dollars to 6,333 dollars and from 35 to 47 hours following the enactment of Pennsylvania maternal minimum LOS legislation. Median infant cost and LOS per delivery mirrored these trends. CONCLUSIONS: Pennsylvania LOS legislation had a profound effect on maternal and infant discharge practices in Philadelphia. As much as $20 million may have been added to annual health care costs associated with Philadelphia resident births.

Child support enforcement program: paternity establishment and revision of child support enforcement program and audit regulations--Office of Child Support Enforcement. Final rule.

This final rule contains provisions regarding both paternity establishment and the audit. The paternity establishment provisions implement the requirements of section 13721 of the Omnibus Budget Reconciliation Act of 1993 (OBRA '93) signed by the President on August 10, 1993, which amends title IV-D of the Social Security Act (the Act). These provisions require States to adopt procedures for a simple civil process for the voluntary acknowledgement of paternity, including early paternity establishment programs in hospitals. For paternity cases that remain contested, the statutory provisions require States to adopt a variety of procedures designed to streamline the paternity establishment process. These include the use of default orders, a presumption of paternity based on genetic test results, conditions for admission of genetic test results as evidence, and expedited decision-making processes for paternity cases in which title IV-D services are being provided. In addition, this final regulation amends the Child Support Enforcement program regulations governing the audit of State Child Support Enforcement (IV-D) programs and the imposition of financial penalties for failure to substantially comply with the requirements of title IV-D of the Act. This regulation specifies how audits will evaluate State compliance with the requirements set forth in title IV-D of the Act and Federal regulations, including requirements resulting from the Family Support Act of 1988 and section 13721 of OBRA '93. This final regulation also redefines substantial compliance to place greater focus on performance and streamlines Part 305 by removing unnecessary sections.

[Who delivers where? Who is born where? Analysis of the 1997-1998 AUDIPOG Sentinel Network]. / Qui accouche où? Qui naît où? Analyse à partir du Réseau Sentinelle AUDIPOG en 1997-98.

OBJECTIVE: The purpose of this study was to describe the care level, legal status and size of the maternity units where deliveries take place in France according to risk level for mother and infant. We analyzed the 1997-1998 data to better implement the network's perinatal policy. MATERIAL: and methods. Our standardized sample included 4200 single births in 1997 and 3650 in 1998 collected by the French Sentinel Network after applying a sample rectification technique to offset the methodological problems created by the volunteer nature of the sample population. Distribution of care level, legal status and size of the maternity unit where deliveries took place were recorded according to the risk level of the patients. RESULTS: In 1997-1998, 22% of pregnant women delivered in level III maternity units and 33% in level II units. Twenty percent of the deliveries took place in level II maternity units with less than 1500 deliveries per year. During this period, women with diabetes or hypertension delivered more often in level III units (31% and 27% respectively) than women in the general population. This was not true for women with a previous perinatal death (23%). Inversely, births of infants before 33 weeks gestation or weighing less than 1500 g occurred more often in level III maternity units (55% and 59% respectively) than in the general population. Twenty-seven percent of the infants requiring neonatal transportation were born in level I maternity units. For 'low risk' mothers, delivery occurred more often in level I maternity units (more than 50%) or in small maternity units with less than 1000 deliveries per year (45%) than for the general population (45% and 36% respectively). CONCLUSION: These data obtained from the Sentinel Network provide precise information on where deliveries occur in France. These data will be useful for implementing the network's perinatal policy. They will also provide a means of following referral practices in the future.

Lessons from the inquiry into Obstetrics and Gynaecology services at King Edward Memorial Hospital 1990-2000.

The Douglas Inquiry investigated the Obstetrics and Gynaecological services at King Edward Memorial Hospital from 1990-2000. Performance deficiencies were identified at state, board and hospital level contributing to poor outcomes for women, babies and families. The Inquiry raises important issues about clinical governance, leadership and culture, accountability and responsibility, safety and quality systems, staff support and development, and concern for patients and their families. The King Edward, Bristol and Royal Melbourne Hospital inquiries reveal important similarities and key lessons for governments, health care leaders and providers. The health care industry must ensure effective clinical governance supporting a culture of inquiry and open disclosure, and must build rigorous systems to monitor and improve health care safety and quality.

Safe deliveries.

Obstetrics, long a patient safety priority because of the vulnerability of mothers and newborns, is even more of a focus thanks to high malpractice costs and an exodus of doctors.

Quick fixes?

Are states' HMO laws solving the problem? When Steve and Michelle Bauman brought home their newborn daughter last May, they had no idea that her death would help prompt New Jersey legislators to action. Yet cases like theirs, most often involving HMOs' policies on coverage for infant delivery, are leading state lawmakers into a whole new--and controversial--area of policymaking.

Clinical IT. Ticker taped.

Paper-traced records of difficult births can be a poor-quality defence in litigation. A newly developed IT system provides an electronic archive of clinical data. A further module to provide automatic decision support is under evaluation.

Reflections on the Canadian MORE(OB) obstetrical risk management programme.

In, 2001, the Patient Safety Division of the Society of Obstetricians and Gynaecologists of Canada initiated and championed a new program to improve patient safety performance in Canadian hospital obstetric units. This new program was developed under the banner of Managing Obstetrical Risk Efficiently and called the MORE(OB) Programme The MORE(OB) Programme was first piloted in Canadian hospitals at the beginning of May 2002 and, by mid 2004, 33 pilot sites had been implemented. In autumn 2004, this program embarked on a national launch. In 2007, the Society of Obstetricians and Gynaecologists of Canada collaborated with the Healthcare Insurance Reciprocal of Canada to form Salus Global Corporation. The birth of this corporate entity embraced the support of rapid expansion of the program within and outside of Canada. This collaboration also enabled innovation and implementation of safety programs beyond the obstetric discipline.