# Presentation: 242083

## Risk Management in Maternal Child Health

**Stephen W. Heath, MD, MPH**
- IHS Risk Management Program
- Office of Clinical & Preventive Services
- Headquarters East

## IHS Risk Management Program

- Solicit peer reviews for all malpractice tort claims filed against IHS or Tribes
- Follow cases through the administrative and litigation processes
- National Practitioner Data Bank reporting
- Tracking and feedback

## Risk Management vs. Patient Safety

- Similar goals – reducing loss, preventing harm
- Proactive vs. Reactive
- Medico-legal: responsibility for outcome often falls on provider
- Patient Safety milieu: focus on the system, not the provider

## Questions for Consideration

- What trends have we seen with respect to provider culpability in perinatal tort claim cases?
- What trends have we seen with respect to system issues in perinatal tort claim cases?
- How can this information help us improve the system, improve the outcome?

## Percentage of Perinatal CasesFY 1987-2006 (1444 cases)

## MCH Study Cases

- Retrospective review of 40 peri-natal cases where one or more providers were named to NPDB
- Allegation, injury type, settlements
- Disciplines named
- Provider culpability and system issues from peer review & Panel comments

## Allegation Class

- Labor Management 	 		17 cases
- Retained Foreign Body  		07
- Missed Dx 				05
- 	(Gest DM-1, Preclamp-2, IUGR-1, Tubal-1)
- Post Partum Management		04
- Delivery Management 		03
- Labor & Delivery Mngmt 		02
- Failure to Refer 			01
- Contraception issue			01//40

## Injury Class

- Infant Death			12 cases
- Infant brain injury		10
- Maternal temp injury	09
- Maternal perm injury	06
- Maternal death		02
- Fetal death			01//40

## Settlements

- Claims allowed	     08 Cases
- Suits settled		     32 Cases
- Range of payments    $9K to $6 million
- Average 40 cases 	     $1,058,150
- Median payment	     $400,000

## Settlements - continued

- $1 million or more – 10 cases
- Infant brain injury (8)
- Maternal perm injury (1)
- Maternal death (1)
- $500K to $999K – 6 Cases
- Infant brain injury (2)
- Maternal perm injury (2)
- Infant death (1 )

## Settlements - continued

- $100K to $442K – 12 Cases
- Infant death (7)
- Maternal perm injury (2)
- Maternal temp injury (2)
- Maternal death (1)
- Less than $100K – 12 Cases
- Maternal temp injury (7)
- Infant death (4)
- Maternal perm (1)

## Provider Disciplines*

- OB/GYN					22 cases
- Non-OB/GYN physicians	11
- Nurse Midwife			10
- Registered Nurse			07
- OB/GYN Resident 			02
- FNP 					01

- * More than one provider named in some cases

## Provider culpability

- Failure to diagnose – 20 cases
- Fetal distress (14)
- Post Partum comp (2)
- HELLP/preclampsia (2)
- IUGR (1)
- Tubal pregnancy (1)

## Provider culpability – continued 

- Improper management – 11 cases
- Forceps (3)
- Delivery (3)
- Post partum hemorrhage (2)
- Equipment use (1)
- Anesthesia (1)
- Contraceptive use (1)

## Provider culpability – continued 

- Sponge retained – 7 cases
- Abdominal (4)
- Vaginal (3)
- Other Issues – 2 cases
- Failure to monitor/transport (1)
- Failure to refer (1)

## System Issues Identified

- Sponge count procedures	7 Cases
- Staffing/coverage			6
- Record keeping			5
- Consult	procedures		5
- Continuity of care			2
- FHT monitor problems		2
- Resident coverage			2

## System Issues Identified

- One case Each
- Availability of blood products
- Communication/consult procedures
- Credentialing & privileging
- Equipment
- Informed consent policies
- Labor protocols