Kung, Adrienne MD; Pratt, Stephen D. MD
Medical error is a leading cause of morbidity and mortality in hospitalized patients in the United States. Much attention has been called to this epidemic by the groundbreaking publication, “To Err is Human,” published by the Institute of Medicine (IOM) in 1999. In this report, it was suggested that up to 98,000 people die each year owing to preventable complications.1 More recent data suggest that the number of medical error–related deaths in the United States far exceeds the mortality associated with automobile crashes (45,000).2 Owing to increasing awareness of the potential harm resulting from medical error, the medical community has been directing emphasis and attention to strategies to decrease medical errors and improve patient safety during the hospital stay. Obstetric anesthesiologists, obstetricians, and obstetric nurses have been particularly instrumental in promoting this patient safety initiative.
The labor and delivery suite is an ideal environment from which to pioneer system-based initiatives to reduce avoidable harm to patients. The suite is unique in that it involves interactions between many different teams, coming from different perspectives taking care of multiple patients, each of which has 2 lives at risk (the parturient and the fetus). As labor and delivery are the most common causes for hospitalization, and cesarean delivery is the most common operation in the United States, exposure to potential medical error is a real possibility for the parturient and the fetus. The actual number of medical errors resulting in adverse outcomes on patients in labor and delivery is difficult to quantify. However, in 2012, Clark and colleagues conducted a prospective study on “near-miss” events on labor and delivery and found them to occur in 0.69% of deliveries. Their team analyzed 203,708 deliveries and defined “near-miss” events as unplanned events caused by medical error that did not result in patient injury but had the potential to do so.3 The data from “near-miss events” are incredibly informative in that they allow us to be proactive in medical error prevention rather than reactive after a tragic outcome has occurred. Others have found that perhaps as many as 9% of parturients will experience an adverse event during their delivery.4,5 It has been suggested that up to 87% of adverse events in the obstetric population are preventable.6
Patient safety in obstetric anesthesia requires a multifaceted approach. In this chapter, we will describe methods to improve patient safety on labor and delivery through the development of a culture of safety, general safety principles, communication strategies, teamwork training, and simulation training.
Culture of Safety and High-reliability Organizations (HROs)
A critical first step in improving safety in the health care system is through the development of a culture of safety. Organizational leadership needs to be committed to creating this culture and implementing it at all levels. Many complex high-hazard industries, including the aviation, petrochemical, and nuclear industries, adhere to this concept of safety culture. Despite being high risk, these industries have defect rates <1:1,000,000, in comparison with the health care industry where error rates have been reported to be as high as 1:10,000. Clearly, much can be learned from these HROs that have significantly lower accident rates, despite being high hazard.
The definition of an HRO is an organization that is able to manage and sustain almost error-free performance, despite operating in hazardous conditions where the consequences of error could be catastrophic.7 These organizations have processes in place that effectively prevent and contain catastrophic errors, enabling them to achieve consistent records of safety over long time periods. In 1993, researchers at the University of California, Berkeley, studied 3 HROs (the Federal Aviation Administration, Pacific Gas and Electric Company’s operation of its nuclear power plant, and the US Navy’s nuclear powered aircraft carriers) and identified characteristics and processes that allowed these organizations to achieve their excellent safety records. These included: deference to expertise during emergencies, management by exception, climate of continuous training, built-in redundancy, and effective communication of critical safety information.7 In 2007, Weick and Sutcliffe8 furthered this research and identified 5 principles of HROs that allowed them to avoid mistakes and continue working effectively when faced with unexpected situations. These principles are:
- Preoccupation with failure: staff does not assume that all will go well, but actively search for ways in which processes might fail.
- Reluctance to simplify interpretations: errors and deviations occur. The evaluation of the root cause(s) does not stop at the first identified. Rather, reviewers continually ask “Why” or “How” each root cause occurred. For instance, investigators would dig deeper into an error that was made owing to a lack of staff knowledge to understand the causes of the knowledge deficit and to help identify or prevent other potential knowledge gaps. This facilitates corrective actions that are more likely to be successful.
- Sensitivity to operations: the daily processes by which the teams operate are the most vulnerable to error (the “sharp end of the stick”). By focusing on these operations, leadership can hope to identify latent errors before they cause harm. This also sets the culture that daily operations are valued and encourages staff to bring problems forward.
- Commitment to resilience: having processes in place that prevent error is important, but will not be 100% effective. Developing processes that help operations recover from error helps to minimize the impact of error on outcomes.
- Deference to expertise: this works to flatten hierarchies. Leaders will not have expertise in every operation. By actively deferring to those with expertise in each process, the processes occur more effectively and a culture of inclusion is developed.
One of the biggest barriers to improving patient safety in health care is this lack of a culture of safety within the health care system. Improving safety culture has been shown to decrease error rates. In contrast with the HROs, studies on the health care system consistently show a lack of organizational commitment in establishing a culture of safety and lack of a blame-free environment.9 In addition, improvement in teamwork and communication, implementing a culture of high expectations, and establishing authority gradients can all have an effect in improving this culture of safety.9 It will undoubtedly be a difficult process in health care to achieve sustained improvements in safety culture, but slow steps can be initiated beginning with our leadership bodies.
General Safety Principles
There are several safety principles that can help in the delivery of best practice care on the labor and delivery ward. Most of these strategies are included in the Joint Commission national patient safety goals, a list of broad safety standards updated each year by the Joint Commission.
The universal protocol was originally created by the Joint Commission in 2003 to address wrong site, wrong procedure, and wrong person surgery. It is the process by which the patient and procedure are appropriately identified before any operative procedure. It has 3 principal components including a preprocedure verification, site marking, and a time out. The name of patient, date of birth, and the proposed procedure (epidural, cesarean section) need to be verified with the parturient before the initiation of the procedure. Site marking is usually not needed on labor and delivery because most procedures are performed in the midline. If procedures are to be performed on the ovary or other lateralized abdominal organs during the time of the cesarean section, a marking would be required on the surgical site. During the final time out, the patient and the surgical procedure are again identified using 2 unique identifiers. This time out is an immediate preoperative pause that occurs in the location where the procedure is being performed. It involves all members participating in the care of the patient: at minimum, the entire obstetric surgical team, the anesthesiologist, and the circulating nurse. There should be no barrier to anyone speaking up during this time. Additional components relevant to the safe care of the patient can be added to the time out such as: prophylactic measures for the prevention of deep vein thrombosis, administration of appropriate antibiotics to prevent surgical site infection, and the availability of extra personnel or equipment that may be needed at the time of the operative procedure. It is noteworthy that the Joint Commission does include the performance of neuraxial techniques for labor analgesia as an indication for a time out. In reviewing the literature for sentinel events occurring on labor and delivery because of failure of the universal protocol, none could be found. Although these errors are rare in the general operating room as well, they can still occur. In a 2006 analysis of insurance claims and malpractice claims, an incidence of 1 in 112,994 was suggested for surgery in general.10 Across all medical fields, and especially on labor and delivery, there is zero tolerance for this type of error and should an event occur, a quality improvement initiative with peer review should be undertaken.
In preoperative and procedural settings, the Joint Commission requires that all medications and solutions not administered immediately should be labeled. The label should include the medication name, strength, quantity, and expiration date and time if not used within 24 hours. This practice is to reduce errors resulting from the administration of unidentifiable medications in unlabeled syringes. This applies to medications used during the administration of neuraxial anesthesia and analgesia as well.
Despite these recommendations, medication error is still a problem and a significant cause of morbidity and mortality. Bates et al11 estimate that 180,000 patients die each year as a consequence of adverse medical events and medication error is a leading cause. Specific to anesthesia, Fasting and Gisvold12 found a rate of 1 medication administration error for every 900 anesthetics performed, with syringe swap being the most common. In a self-reported survey study on 687 anesthesiologists conducted by Orser et al2 in Canada, syringe swap (70.4%) and misidentification of the label (46.8%) were the most common contributing factors to medication error. The authors advocated improving labeling and packaging standards, similar to the initiative taken by the Center for Patient Safety in the United States in 1999. Medication error can have devastating consequences during neuraxial placement.
As neuraxial anesthesia is a large portion of our practice in obstetric anesthesia, medication safety during epidural placement is especially relevant on the labor and delivery floor. Serious morbidities such as paraplegia, quadriplegia, sensory changes, and bladder/bowel incontinence have been reported. In a Medline search study conducted by Hew et al13 in Australia, the authors found 37 cases of medication error during epidural placement over a period of 35 years, with syringe swap once again being the most common cause of error. A wide array of epidural and spinal medication administration errors have been described, including: muscle relaxants, antibiotics, magnesium, insulin, potassium, and thiopental. Medication error themes during neuraxial placement included wrong ampule for drug dilution, performance of loss of resistance technique with incorrect fluid in the syringe, and intravenous/epidural line confusion. Syringe swap most commonly involved similar-sized syringes that may or may not have been labeled. Reverse neuraxial medication errors have also been reported, with intravenous administration of medications intended for the epidural space. This can lead to local anesthetic toxicity, seizures, cardiac arrhythmias, and death. Given that there is no effective treatment for a majority of the complications (especially those that would occur in the spinal or epidural space), medication error remains the most preventable cause of patient injury. The authors suggested that prevention could be achieved during drug preparation and epidural drug administration (double checking with another person) and by labeling. The use of color-coded labels has been a mainstay of medication safety in anesthesia for a long time, but its effectiveness as a safety measure is unproven.12 The Institute for Safe Medication Practices has actually published warnings about the potential dangers of color coding, including the possibility of actually increasing syringe swap within the medication class that have the same label color.14 The use of barcode scanning offers a potential breakthrough in medication safety in the operating room. These systems require the clinician to scan the medication vial or ampule and will then print a barcoded, colored label. The barcode can then be scanned before administration, and the medication corroborated audibly or on a screen. These devices are generally easy to use and well accepted by clinicians.15 Fedorko16 implemented a barcoding system in 20 operating rooms in a major Toronto hospital. After the first 60,000 doses there were no reported medication errors, but 29 near-misses that had been prevented by the scanner. After 23 months and >300,000 doses, there had not been 1 medication error reported. Another more recent innovation in preventing medication error during neuraxial placement is the development of noninterchangeable epidural and IV connectors. The recommendation that epidural and IV connections be noninterchangeable was made more than a decade ago,17 and yet little progress has been made, despite continued calls for this change.18 These connections are currently unavailable in the United States, and although they are available in Europe, their penetrance into the market seems to be limited. Clinician acceptance of these devices seems to be mixed in both the simulated environment19,20 and clinical practice.21 Although not yet universally available, this design could allow for safer practice on labor and delivery floors.22
Avoidance of Prohibited Abbreviations
The “do not use” list of abbreviations was created by the Joint Commission in 2004. It met a National Patient Safety Goal requiring accredited organizations to develop and implement a list of abbreviations not to use. This was in response to a tragic death of an infant that resulted from a misinterpretation of a prescription for morphine. Most medical centers have created a list of approved and prohibited abbreviations that are followed by clinicians in the obstetric unit. Table 1 illustrates such a list.
It is evident that many of these medications are a part of our daily practice and can be a source of latent error on the labor and delivery floor. Magnesium sulfate is commonly used in obstetrics, and intrathecal morphine is a frequent drug used by anesthesia during labor and cesarean section. Pitocin (oxytocin), another common medication in obstetrics, is prescribed and dispensed in units. As anesthesiologists, we are often directly administering the medications and do not have the benefit of a repeat check from the pharmacy. Our accuracy and discrimination in medication written orders and administration can have a great impact on patient safety in the labor and delivery unit.
One of the specific recommendations of the IOM report was an increased attention to handoffs.1 Handoff of care is a structured, interactive process of passing off information from one caregiver to another for the purpose of ensuring continuity and safety of patient care. It is a National Patient Safety Goal developed by the Joint Commission. All accredited institutions are required to implement these goals. Inadequate handoff is a source of patient harm and malpractice claims. The Controlled Risk Insurance Company (CRICO), of the Harvard Medical Institutions, reports that over the past 5 years handoff-related cases represent >$173 million in incurred losses for CRICO-insured institutions. In addition, in more than half of those cases the patients involved sustained a high-severity injury.23 There are 4 types of handoff of care: change in the level of care, temporary transfer of care, discharge, and change in provider/service. As obstetric anesthesiologists, we are most frequently involved in handoffs during transfer of care at the end of a shift. This is a high-risk time period for loss of vital clinical information. This is especially problematic in obstetrics because clinical information affects 2 patients, the mother and the fetus. In addition, often owing to sensitivity to patient emotions and the personal, family-centered experience of birth, much information is exchanged behind closed doors. Despite the importance of and clearly barriers to the transfer of information in obstetrics and obstetric anesthesia, there is still no large-scale structured process for handoffs. Obstetric anesthesia handoffs are frequently inadequate, short, interrupted by clinical care, and poorly structured.24 Poor communication and coordination of care has been identified in 43% of closed malpractice claims in obstetrics.25 At our institution, we have implemented a structured process and template to help improve the quality of information transfer during handoffs. At each new patient encounter, a card with relevant patient demographics, medications, and laboratory values is filled out by the anesthesiologist. This same card is updated throughout the day with new results and plans and is used to facilitate patient handoff during the “sign out” period at the end of a shift.
Clinical protocols provide a comprehensive set of criteria outlining the management steps for a particular clinical condition. They are an effective way to decrease practice variability and improve patient care. They are usually evidence-based guidelines that can be a readily accessible reference for members of the clinical team. In the labor and delivery suite where multiple teams are involved in the care of a parturient and fetus, it allows different team members to anticipate the next step and identify unsafe deviations. Obstetric clinical protocols may include: management of maternal hemorrhage, use of oxytocin, management of induction of labor, thromboprophylaxis, and monitoring during magnesium infusion. Emergency clinical protocols are documented on laminated boards in well-visualized areas in the operating rooms. The obstetric anesthesiologist should be aware of the obstetric protocols in their institution so that they can be effective team members when the clinical situation arises.
According to estimates from the Centers for Disease Control and Prevention (CDC), each year nearly 2 million patients in the United States get an infection in hospitals and about 90,000 patients die as a result of their infection. The parturient and the fetus are a patient population that is particularly vulnerable to hospital-acquired infections. The Joint Commission recommends compliance with the CDC guidelines that advise the use of alcohol-based hand rubs in conjunction with traditional soap and water, and sterile gloves to protect patients in health care settings. These guidelines are part of an overall CDC strategy to reduce infections in health care settings and to prevent the spread of germs from one patient to another by improving hand hygiene. Unfortunately, recent studies cite hand hygiene as being poor among anesthesia providers. Biddle and Shah26 observed the hand hygiene of anesthesia providers in a teaching institution over a 4-week perioperative period and found an aggregate failure rate of 82%. This is an issue that is especially relevant to obstetric anesthesia providers as we often deal with sterility during epidural placement and the complications thereafter. Fortunately, meningitis and epidural abscess are uncommon in the obstetric population, but when they do occur the results can be devastating. Moen et al27 detected 29 cases of meningitis in 1,260,000 spinal anesthetics for surgical patients, but none among the 55,000 spinals for cesarean section. In this same study, there were 12 epidural abscesses among 450,000 surgical epidurals and 1 among 200,000 for labor. This complication is so rare among the obstetric population that it is difficult to pinpoint sentinel events and causal factors. Recommended measures to prevent neuraxial infection are not evidence based but are extrapolated from other fields of infection control. These recommendations include: washing hands thoroughly in an alcohol wash, removing hand jewelry, wearing a hat and mask and changing between patients, donning powder-free sterile gloves, cleaning the patient’s skin widely with iodine or alcohol/chlorhexidine-based solutions, ensuring the area is securely draped and avoiding contaminating equipment, and finally, avoiding prolonged epidural catheterization in the presence of immunocompromise or after multiple attempts at insertion.28 As obstetric anesthesia providers taking care of patients in the operating room during cesarean section and neuroaxial placement during labor and delivery, it is incredibly important that we are cognizant of hand hygiene and its implications on infection control.
Specific Safety Training
Each of the safety activities identified above should be part of broad, hospital-wide safety efforts expected of all procedural areas. Beyond these areas, however, obstetricians and obstetric anesthesiologists have made major contributions in patient safety specific to the labor and delivery environment. These include improvements in communication, use of team training, and simulation.
The obstetric unit is unique in that team members from different disciplines are involved in the care of the parturient and the fetus. Critical decisions on complex medical issues often need to be made quickly with less than complete information. It is easy to see how failures in teamwork and communication can contribute substantially to patient harm. There is a growing body of literature that communication error in the operating room increases the risk for surgical complications. Lingard et al29 found that over 25% of operating room communications failed, resulting in inefficiency, waste, delay, tension, and procedural error. Specific to obstetrics, the communication between obstetricians and anesthesiologists is a crucial factor in safe delivery by cesarean section. The UK confidential enquiries reported substandard care in 55% to 77% of maternal deaths. Poor communication was a major factor.30 Up to 72% of neonatal adverse events can be similarly attributed to poor communication.31 Approximately 43% of malpractice cases could have been prevented or mitigated with improved communication or teamwork.25,32 Communication in the labor ward is often inadequate. Simpson et al33 found that obstetric nurses and obstetricians may communicate for only several minutes over the entire course of labor. Using in situ-simulated eclampsia drills, Thompson et al34 found that timely communication with senior obstetric staff was a recurrent problem. Similarly, Daniels and colleagues demonstrated that obstetric residents communicated poorly with their pediatric team members during a simulated emergent delivery. Although 63% called for pediatric help during the simulated maternal cardiopulmonary arrest, only 10% gave helpful information to the pediatricians when they arrived.35 As anesthesiologists, to improve our communication skills on labor and delivery, we have to understand the causal factors for communication error and methods to collaborate with other health professionals.
Causes of Poor Communication
The failure to communicate occurs when the receiver understands a different message than was intended by the sender. There is a responsibility on both the receiver and the sender to ensure proper message content. Causal factors for communication failure include: interruptions, fear, stress, and overcommunication. Interruptions are present in as many as 30% of communication events in the perioperative period. Fear can negatively impact the willingness of a subordinate to question the content of a communication when it is not completely understood. Stress from a heavy workload, difficult case, or personal reasons can be detrimental to communicating effectively. Moreover, team members who are subjected to high-frequency communication may not be able to focus on the key information at hand. For example, resource nurses on labor and delivery can receive dozens of communications in an hour.
Types of Communication Failure
There is a growing body of literature analyzing and classifying communication failures. Lingard and colleagues conducted a study analyzing 421 communication events in the operating room and found 129 communication failures. These failures were classified into 4 major types: occasion, content, audience, and purpose (Table 2).29 These types of failures can also be applied toward communications on the labor and delivery floor.
Ensuring Content of Communication in the Labor and Delivery Suite
For patient safety, there are certain key points that need to be always communicated between the obstetrician, anesthesiologist, and nurses on the labor and delivery floor.
All the members of the labor and delivery team should know the location of the covering obstetrician and anesthesiologist. They should know how to reach them in a timely manner, and who is covering for them if they cannot be reached. At our institution, the names and pagers of the covering obstetrician and anesthesiologist are written on a board in a central, well-visualized location. If another attending is covering while the primary staff is occupied in the operating room, this is documented on the “white board.”
All the care providers should be aware of the clinical plan for a patient before it is carried out. This can allow other providers to anticipate steps that need to be taken ahead of time, to identify unsafe deviations from the plan, or to identify changes in circumstances that should lead to a review or change of the plan.
Patient concerns should be freely discussed by the different teams and specialties taking care of the patient. Each specialty has its own expertise and will likely bring different viewpoints regarding the care of the patient. For instance, the laboring patient whose fetus is having recurrent, deep variable decelerations would have a different risk profile if she had a functioning epidural compared with no epidural and a Mallampati class IV airway.
There are several methods and events that can facilitate communication among team members throughout the course of the day. These include time outs, preprocedure briefings, team meetings, debriefings, and templates/checklists.
As discussed previously, the time out is a Joint Commission–regulated component of patient safety communication. It needs to occur before any procedure being performed and needs to involve all members of the team. It is also an opportunity for exchange of pertinent additional information and concerns.
There is growing evidence that preoperative briefings can reduce communication errors and potential for incidents.36 Many comparisons have been drawn between the aviation industry and the operating room in that both are high risk, stressful environments where many different teams must collaborate toward a common goal. In aviation, crew resource management (CRM) has standardized team work and communication to improve passenger safety. CRM is a set of behaviors and communication techniques designed to improve coordination of crew actions, eliminate hierarchies, define members’ roles, and effectively resolve conflicts. One component of CRM is the use of preflight briefings to prepare teams to anticipate threats and minimize error potential.37 In the general operating rooms, the preoperative briefings have been found to improve team communication, interprofessional insight, and enhance the sense of team culture.38
Although this is not as well proven in obstetrics, briefings have been used as part of the patient safety initiative. On our unit, we carry out a multidisciplinary briefing before every cesarean section. The entire team meets in a central location and a template is used to ensure all relevant topics are covered. A multidisciplinary team meeting reviewing the entire labor and delivery board can help facilitate communication among different members of the team. This meeting occurs at every shift at our institution, or can also be organized ad hoc by any member of the team, when a need for patient discussion arises. Several times, plans have changed owing to awareness about other issues that are more pressing on the unit.
Debriefings after an operative or procedural incident can help identify problems and concerns. Quality improvement initiatives can be formally taken after a debriefing meeting calls to attention an intraoperative event. In our institution, any member of the clinical team can initiate a debriefing meeting when the situation warrants it.
Finally, the use of templates or checklists can be an instrumental tool in facilitating communication on the labor and delivery floor. This is another task derived from the aviation industry model of safe practices. In the general operating room, anesthesiologists routinely use checklists for machine checks and preoperative patient care. In a study on over 7500 patients in the UK, the introduction of the World Health Organization (WHO) 3-stage perioperative checklist reduced the relative risk of surgery-related deaths by 46% and complications by 36%.39 Checklists can be used on the labor and delivery floor to ensure that all appropriate communication events and content have been completed. In a retrospective audit study, Mohammed and colleagues evaluated the impact of the WHO checklist on communication between the anesthesiologist and obstetricians in a teaching hospital in the UK. They found that the use of a checklist improved the communication of cesarean section urgency between obstetricians and anesthesiologists.40 In a survey study conducted by Kearns and colleagues, the authors found that use of a surgical safety checklist on the obstetric floor improved interprofessional communication and promoted familiarity among team members. However, they did note that the staff was generally more receptive to checklists in elective cases as compared with emergent cases where it can be argued that checklists have an even greater utility.41 It is clear that checklists can help in communication between teams on the labor and delivery floor, but further work is required to optimize this process.
Tools for Communication
There are several tools for communication that can help ensure that the content of the message received was the same as what was intended by the sender. These techniques include check back, directed communication, SBAR, and the 2-challenge rule (Table 3). The check back technique is one of the most important techniques. It is the process in which the receiver repeats the message back to the sender. Using directed communication is crucial, especially during an emergency. It is always more effective to direct a request to a particular person rather than making a general request. For instance, asking a specific nurse to get 4 units of packed red blood cells from the blood bank and allowing her to respond is much more effective during a massive maternal hemorrhage than yelling, “Someone get me some blood in here.” The first method assures that the task will be completed and prevents multiple people from doing the task and thus wasting resources. SBAR (situation, background, assessment, and recommendation) is a technique modeled upon naval military procedures that were adapted to health care.42 It has been shown to improve transfer of information during handoffs. Situation refers to identifying the caregiver and the patient, background is the summary of the patient background, assessment would include vital signs/patient clinical impression, and recommendation would be the action that needs to be taken. Finally, the 2-challenge rule is the expectation that a concern about a clinical action is raised twice. Clinicians should commend those that respectfully challenge care and advocate for safety.
Available evidence suggests that effective communication techniques can be learned through simulation. Siassakos et al43 demonstrated that simulation training, both in situ and in a simulation center, was associated with improved clinicians’ use of closed-loop and directed communication, and patients’ sense of safety.44 In a follow-up study, the investigators found that the simulation training was also associated with improved communication with the patient.45 Specifically, clinicians spoke to the simulated patient more often and for more total time. They were more likely to tell the patient the nature of the emergency and the immediate treatment. The authors found significant variation among providers in the amount and quality of this communication, suggesting that simulation could be a tool to identify those with a need for more communication training. Pian-Smith et al46 demonstrated that residents could be taught to more effectively challenge potentially dangerous decisions made by attending providers using the 2-challenge rule. Taken together, these 3 studies suggest that the communication skills required for effective communication can be learned through simulation.
The team training model in medicine is also derived from the concepts of CRM in military aviation. The teams on labor and delivery consist of separate professional groups with different training backgrounds and biases that may affect their interactions with one another. It is logical to see how a team training model can help with communication and coordination of these different groups to optimize performance.
Model of Teamwork
Salas et al47 broke down the model of teamwork into a framework of 5 core components: leadership, mutual performance monitoring, backup behavior, adaptability, and team orientation. Table 4 describes the components of the “big five” in greater detail.
In addition to these 5 dimensions, the underpinnings of mutual trust, closed loop communication, and a shared team mental model are important to the coordination of medical team training.47 As medical disciplines often have different biases and perceptions, this concept of team training will require effort to implement in current medical climates. Weller and Merry48 identified that one of the biggest challenges is convincing anesthesiologists that the science of patient safety and teamwork training is as relevant to daily practice as pharmacology and physiology.
Even with an effective strategy and implementation plan, the incorporation of teamwork behaviors and cultures onto a labor and delivery unit can take months or years. Pratt and colleagues trained >220 individuals in a classroom-based CRM teamwork course. The authors described a structured implementation process involving the use of templates, structured language, coaches, and 3 types of formal teams that helped to translate the behaviors to the clinical environment.5 A multiyear process was necessary to fully integrate all the team concepts. Similarly, Pettker et al,49 Grunebaum et al,50 and Clark51 found that the inclusion of teamwork concepts into a multifaceted patient safety program in obstetrics required years to achieve.
Evidence That Teamwork is Effective
It is clear that team training is effective in the medical setting. In a meta-analysis of studies of 2650 nonclinical teams, the authors attributed 20% of differences in team processes and outcomes to prior team training.52 A retrospective study conducted by the Veterans Health Administration in 74 facilities found an 18% reduction in annual mortality after participation in a 2-month operating room team training program.53 There is considerable evidence in obstetrics that team training does improve patient outcomes. To date, only 1 prospective randomized trial of the impact of teamwork on obstetric outcome has been conducted.4 This did not demonstrate an improvement in patient outcomes, but it did find that teamwork was associated with a 33% improvement in the time to incision during emergent cesarean delivery. Using other methodology, others have demonstrated improvements in patient outcomes associated with both classroom and simulation-based team training. In the study described above, Pratt and colleagues found that both the rate and severity of adverse events (as measured by a 10-item weighted Adverse Outcomes Index54) were decreased after team training.5 Similarly, Pettker described a multistep process designed to improve safety on their labor and delivery unit, including the development of clinical protocols, fetal monitoring certification, a safety nursing committee, and team training. The adverse event rate, again measured by the Adverse Outcomes Index, decreased by nearly 28% in the second half of the study period.49 In addition, the percentage of nurses and physicians that reported a “good teamwork climate” increased from 16.4% and 39.5% to 72.2% and 88.7%, respectively. Using a similar multistep model that mandated CRM-based team training, Grunebaum et al50 described a marked drop in the number of sentinel events on their obstetrics unit. Team training was the first of 19 individual safety steps implemented over a 6-year period. The unit experienced 3 to 5 sentinel events per year at the start of the program, but only 3 total events over the last 5 years. Shea-Lewis55 found a 43% reduction in the rate of adverse obstetric events after the implementation of a CRM-based team training curriculum in an intermediate-sized community hospital. Phipps et al56 evaluated the implementation of a labor and delivery team training program that included didactic sessions and a simulation component and found improvement in patient outcomes and perceptions of patient safety. Finally, in a landmark paper, Draycott and colleagues developed a 1-day course that combined didactic and simulation training in both teamwork behaviors and obstetric crisis management. All obstetric care providers at a large, urban center were required to attend the course in multidisciplinary sessions. Evaluation of >19,000 deliveries during the 2 years before and 3 years after training demonstrated a 50% risk reduction in the rate of neonatal hypoxic ischemic encephalopathy after the training.57 Although it was unclear whether the improvement was related to better clinical care or better teamwork, the decrease in the rate of hypoxic brain injury is remarkable.
It is recognized that team training does improve patient outcomes in the labor and delivery unit; the challenge now is establishing the best way to teach teamwork in the clinical environment and how to ensure that the knowledge is sustained. Written material, didactic sessions, simulation, case study and vignettes, and practice and feedback in the clinical environment have all been used.
Simulation is an effective tool for teaching team training and technical skills, for assessing clinical performance to identify potential areas for improvement, and to artificially stress a work environment to find potentially dangerous but hidden conditions. Like team training, it is derived from the CRM training program of the aviation industry. In 1990, Gaba et al58 at Stanford recognized the potential of simulation-based team training and adopted this model to develop the Anesthesia Crisis Resource Management program. This approach teaches team behavior strategies in crisis solutions and assesses decision making, interpersonal communication, and team management. Since then, simulation has become commonplace in medical education and has been used in the field of obstetric anesthesia to teach individual technical/clinical skills, group models, and teamwork.
Simulation has been used by obstetric anesthesiologists to improve numerous technical skills. Some examples include: blood loss estimation, airway management, epidural placement, ACLS performance, and management of cesarean delivery.59 Toledo and colleagues found that during a simulated obstetric massive hemorrhage, clinicians underestimated the degree of maternal blood loss by 38% (range, 20% to 59%). The study participants attended lectures on blood loss and interacted in a blood loss simulation. After the training, blood loss underestimation decreased to 4%.60 Airway management skills and the algorithm for failed airway are of particular importance in obstetric anesthesia. As most anesthetics on labor and delivery are performed under neuraxial technique, many obstetric anesthesiologists are not able to practice airway management in the parturient on a frequent basis and may lose airway management skills in this population at a high risk for difficult intubation.61,62 Simulation may be instrumental in filling that void.63,64 Several epidural simulators, ranging from a “green-grocer” simulator made of a banana, a slice of bread, a balloon, and an intubating pillow65 to very high-technology simulators,66,67 have been described. They have been shown to improve resident neuraxial technique and identification of the epidural space. Simulation has also identified deficiencies in ACLS performance68,69 and led to the recommendation that OB-specific ACLS training be incorporated into obstetric training.70 Scavone et al71 developed a scoring system to assess resident performance during a simulated general anesthetic in a parturient. Participation in simulation is slowly becoming a part of resident and staff evaluation and staff recertification. However, there is no evidence that an exemplary simulation performance correlates with clinical performance.59
Team Training and Simulation
Teamwork is a specialized, nontechnical skill, but has been largely studied separately from other simulation-based skills training. Simulation is an ideal way to teach teamwork training. Much of the teamwork training relies on teaching team functioning skills such as communication behavior, leadership skills, and mutual performance monitoring. The simulation environment is helpful in that it allows the acquisition of these skills in the context of a clinical environment. Studies show that most clinicians enjoy learning these skills in this type of simulated environment and feel that it improved their teamwork skills.72 Gardner et al25 found that 1 year after an obstetric simulation in crisis management and teamwork, providers reported that they communicated more effectively, debriefed more thoroughly, and responded better to crisis.
The impact of team training–based simulation on obstetric outcomes is not well established. It has been argued that when simulation is used to teach clinical skills in obstetrics, the addition of specific teamwork training is not needed or helpful.73,74 However, Riley et al75 found that multidisciplinary team training alone did not improve obstetric outcomes; however, the addition of a series of in situ simulation exercises to the teamwork training was associated with a sustained 37% improvement in adverse events. More work is needed to determine the impact of simulation-based team training on teamwork behaviors in the clinical environment and patient outcomes.
The simulated environment is ideal for assessing performance in a clinical environment. The actual simulation (drill) takes place in the labor and delivery unit with a mannequin or actor portraying a patient. This setup has been used to perform drills in maternal hemorrhage, eclampsia, failed intubation, and cardiac arrest in situ. These drills could test how quickly the team could initiate a cesarean delivery during a maternal code or how quickly an anesthetic provider could get advanced airway equipment during a mock-failed intubation. The advantages are that the entire staff can be trained simultaneously, weaknesses in the system can be identified, and this training can occur without leaving the clinical environment.59 Thompson et al34 ran eclampsia drills on their unit and found communication and coordination failures, inefficiencies, and deficiencies in clinical skill. The simulation led to immediate and concrete changes in the unit, including the development of an eclampsia tackle box. Riley et al76 studied teamwork behaviors during in situ-simulated crises in 6 hospitals ranging from 700 to 3300 deliveries per year. The authors found only fair scores in teamwork behaviors (leadership, situation awareness, closed-loop communication, and shared mental model). These scores tended to decrease as the acuity of the simulated scenario increased. The authors made several observations regarding team performance. First, the mother was the only consistent member of the team throughout all stages of the crisis, demonstrating the importance of including her whenever possible. Second, they calculated that with 208 clinicians on their unit, there are 381 million combinations of staff that could make up the team on any given shift. Thus, although the staff knew each other well as individuals, and believed that they could communicate and perform well together, these assumptions could and did lead to miscommunications and errors. Osman et al77 conducted eclampsia and maternal hemorrhage drills in 3 hospitals. They identified multiple system problems within each unit that limited the quality of the care provided. The simulation allowed these latent errors to be identified and solved without placing patients at risk. At the University of Michigan, Andreatta et al78 found discrepancies in many of the policies and clinical practices designed to improve patient safety during obstetric emergencies. Some of these policies were just confusing, difficult to find, or unhelpful. Other policies directly contradicted what the clinicians felt was best practice or created mutually exclusive requirements. Each of the 16 simulation scenarios was associated with multiple discrepant policies (range, 11 to 28). Using a similar design, Guise et al79 found multiple unsafe conditions across 6 hospitals. These conditions included equipment, medication, staffing, communication, and policy issues. In each situation, the in situ simulation allowed the labor and delivery team to identify potentially unsafe conditions (latent errors), and to correct them before patients were placed at risk or harmed.
Nonfatal medical injuries resulting in disability or prolonged hospital stay occur in 1.3 million US patients per year. As more and more data accumulate, it is becoming increasingly clear that errors in medicine are not negligible and are often preventable. Using other high-risk industries as role models, we have gone away from individual culpability and toward system-based improvements to minimize human error. Medicine as a field is becoming increasingly complex as several different teams from several different shifts are often involved in the management of a single patient. For this reason, it is now more important than ever that we focus on examining medical systems and processes for prevention of error.
As an individual on the labor and delivery floor, there are several things that can be done to advocate for patient safety. The individual clinician can help leadership establish protocols, initiate simulation and team training, and prioritize other safety activities. Practicing effective communication and practicing teamwork behaviors whenever possible can help foster an environment conducive to patient safety. Finally, physician self-care is vital in the prevention of adverse events on the labor and delivery floor. Fatigue and burnout are associated with increased rates of complications. It is important that clinicians monitor themselves and others for signs of fatigue and stress to help prevent negative patient outcomes. Hopefully, through increasing patient safety initiatives, practice of patient safety behaviors, and self-care, we can continue to improve clinical care and decrease medical error in the labor and delivery suite.
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