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OB/GYN Editorial August 2004
Liability Tort Reform: Not a Done Deal
Ronald T. Burkman, MD
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The liability crisis in medicine in the United States shows no
significant sign of abatement. As of early June 2004, in my own
state of Massachusetts, although there had been some legislative
activity to pass some type of tort reform, it clearly is not a "done
deal." In fact, it is unlikely that any bill will fully address
what is needed. At the federal level, party politics are in play
and most observers feel there is little chance that anything will
be enacted before the upcoming election. On the positive side,
some bills being debated are trying to address one of the components
that lead to lawsuits: avoidable medical errors. In fact, it is
my own opinion that we should push, at least at the state level,
for tort reform legislation to include provisions that would help
establish and fund error prevention programs. I view such legislation
as being proactive and supportive of a view that real reform should
revolve around prevention of complications rather than dealing
only with the aftermath. Such legislation should include protection
against lawsuits if hospitals and physicians agree to share and
openly discuss bad outcomes among care providers that have occurred
in a variety of settings. Such reviews would allow strategies to
be developed that could reduce the occurrence of such mishaps.
However, without protection against lawsuits, such data will not
be shared in a meaningful way.
What is being done currently to address error prevention and does
it work? There are a number of programs underway in many institutions
that attempt to address errors globally rather than just on one
service. For example, computerized order entry systems that are
linked to pharmacy systems avoid dosing errors, notate allergies,
and can point out interactions. Some hospitals have established
error reporting systems that include "near misses" and
which encourage everyone in the organization to point out systems
problems that could lead to an error. Site of surgery labeling
with "time-outs" will reduce wrong-site surgery, a problem
that is far more prevalent than most institutions want to admit.
An obvious question is whether error prevention always requires
significant technological utilization. Two projects that have involved
our OB/GYN department suggest how one can see important gains with
approaches that I would call "back to basics." For example,
in our department, we determined that shoulder dystocia accounted
for about 25% of settled obstetric claims in our area as well as
in the Northeast. In reviewing our own experience, it appears that
with a serious event, provider roles are not always understood,
release maneuvers may not be performed well, and documentation
may be lacking. We developed a program that demonstrated how to
appropriately perform the maneuvers, indicated the function of
each team member, and stressed patient counseling and documentation.
The program is being utilized for physicians, house staff, midwifes,
and nurses. Participants have noted significant improvement in
the process of managing shoulder dystocia, particularly the more
severe cases. We now require the program as part of obstetric credentialing
and re-credentialing. Further, we have developed a CD-ROM which
allows individuals to go through the material on their own, but
which includes a built-in posttest that requires a total score
of 80% to "pass."
Another program that we are involved in is MedTeams, which is a
nationwide project designed to test whether team-training on labor
and delivery improves obstetric patient safety by reducing the
occurrence of adverse outcomes while enhancing patient and provider
outcomes. The training is modeled after approaches that have been
used in reducing errors on the flight deck of aircraft carriers
as well as other sites. A total of 16 civilian and military medical
centers have been involved in the project, which includes a randomized
trial to see if the training is effective. Results of the study
should be available in a few months. However, when one examines
the actual team training, there is an extensive focus on breaking
down barriers among physicians, nurses, and other care providers,
and utilizing methods to improve communication, problem solving,
manage workload, and improve overall team skills. When examined
in the abstract, the methodology is not "rocket science," but
it does require care providers to abandon their "work silos," discard
the "captain of the ship" mentality, and think far differently
on how health care is managed. The bottom line with both of these
examples is that we have to start thinking out of the box if we
really want to reduce medical errors and address true systems issues.
If we are successful, our efforts will gain broad support from
many sectors, enhance our image with the public, and go a long
way toward shifting the focus on errors away from the tort system.
The effort will take commitment and the journey is longer then
we think, but ultimately, it is worth it for ourselves and for
our patients.
Ronald T. Burkman, MD
Associate Advisory Board Member
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