Practice Makes Perfect–Or Does It?
Burkman R
The Female Patient.2011;36(8):8-9

As is well known by most practicing ObGyns, the Institute of Medicine reports in 2000 and 2001 pointed out significant problems related to patient safety in the United States, preventable problems that in many instances led to deaths or morbidity. The reports suggested there were a number of approaches that could be taken to alter this situation.

One of the recommendations was that team training could reduce medical errors and improve patient safety. Th is advice was based on the experience of the airline industry, in which safety markedly improved when such methods were undertaken. Hospitals across the country have embarked on team training (also known as crew resource management) using a variety of programs. All programs tend to have the shared vision that better patient outcomes will result from improving communication among caregivers; ensuring that all members of the health care team accept responsibility for patients on their unit; standardizing aspects of care when appropriate; and respecting the opinions of all members of the team.

Another approach is to employ the principles of team training in drills used to simulate serious emergent clinical events that are often uncommon. The principle is that through such simulation, participants will be able to perform better when a real event occurs. An early example in medicine of this approach is the various CPR courses designed by the American Heart Association.

Simulation drills are now being conducted on obstetric units or in special simulation centers for emergencies such as shoulder dystocia, postpartum hemorrhage, and eclampsia. Intuitively, one would expect that such training would lead to documented improvement in maternal and neonatal outcomes. However, documented clinical improvement in the world of obstetric simulation remains for the most part illusive.

In a review of 97 articles on simulation training in obstetrics, Merien and colleagues noted that demonstration of the clinical effectiveness of team simulation training compared to conventional training in obstetric emergencies is lacking, for the most part. In their review, only 8 articles were deemed potentially relevant, with only one study demonstrating improvement. This latter paper documented an annual mandatory one-day course utilizing multidisciplinary team simulation training for obstetric care providers. It covered CPR for adults and the neonate, shoulder dystocia, postpartum hemorrhage, breech delivery, twin delivery, and eclampsia. The team simulation led to better Apgar scores and a reduced frequency of hypoxic ischemic encephalopathy in infants over a 5-year period.

An obvious question is: Why is it so hard to document better outcomes? One explanation is that Practice Makes Perfect —Or Does It? Documented clinical outcomes in the world of obstetric simulation remain for the most part elusive—many of the benefi ts relate to improvements in communication, knowledge, and documentation. EDITORIAL Ronald T. Burkman, MD Follow The Female Patient on and The Female Patient | VOL 36 AUGUST 2011 9 Ronald T. Burkman, MD Editor-in-Chief many of these events are infrequent, such that it would take years for many institutions to show a statistically signifi cant change. Some of the benefi ts may not be measured in the usual clinical context. For example, many of the benefits of team simulation relate to improvements in communication, knowledge, and documentation. Although such improvements are measurable, they are not usually classified as clinical outcomes.

In summary, certainly all of us would like to see the error rates in medical care reduced and improvement in issues that adversely affect quality. Further, most of us would like to be much more proactive rather than passive.

The bottom line is that although such training has value, one needs to understand that documenting improvement using standard clinical outcome measures in the short term will be challenging. That said, we must still attempt to be as evidence-based as possible with quality improvement projects such as simulation training, in order to eliminate those that are ineffective and wasteful of time and money.


In this issue on page 11, The Female Patient is proud to introduce a new column on Lifestyle & Health for the practicing clinician. Board member Patricia J. Sulak, MD, will be contributing her bimonthly series "Wellness: Habits That Lead to Health and Happiness."

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Ronald T. Burkman, MD

Suggested Reading


Draycott T, Sibanda T, Owen L, et al. Does training in obstetric emergencies improve neonatal outcome? BJOG. 2006;113(2):177-182.

Institute of Medicine, Committee on Quality Health Care in America. Crossing the Quality Chasm; A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.

Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Institute of Medicine. Washington, DC: National Academies Press; 2000.

Merién AE, van de Ven J, Mol BW, Houterman S, Oei SG. Multidisciplinary team training in a simulation setting for acute obstetric emergencies: a systematic review. Obstet Gynecol. 2010;115(5):1021-1031.

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