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The Role of Obstetrical Claims in Medical liability

The Role of Obstetrical Claims in Medical liability. Alethia (Lee) Morgan, M.D. FACOG Patient Safety and Risk Management COPIC. Disclosure. I have no relevant financial relationships to disclose. What is in it for you today. Impact of OB/GYN claims on medical liability

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The Role of Obstetrical Claims in Medical liability

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  1. The Role of Obstetrical Claims in Medical liability Alethia (Lee) Morgan, M.D. FACOG Patient Safety and Risk Management COPIC

  2. Disclosure I have no relevant financial relationships to disclose

  3. What is in it for you today Impact of OB/GYN claims on medical liability Impact medical liability rates on access to OB care COPIC experience Patient safety in OB

  4. What specialty spends the highest percentage of their annual net income on PLI coverage? Pediatrics Obstetrics/Gynecology Orthopedic Surgery Emergency Medicine Neurosurgery

  5. What specialty spends the highest percentage of their annual net income on PLI coverage? Pediatrics Obstetrics/Gynecology Orthopedic Surgery Emergency Medicine Neurosurgery

  6. ACOG 2006 Professional Liability SurveyLiability Claims Experience At least 1 claim filed against 89.2% respondents during their career Average number of claims filed 2.62% against all ’06 respondents At least 1 claim filed against respondents during their residency 37.3%

  7. ACOG 2006 Professional Liability SurveyLiability Claims Experience 1996199920032006 At least 1 claim filed 73% 76.5% 76.3% 89.2% during their career Average number of claims 2.31 2.53 2.64 2.62 filed At least 1 claim filed during their residency 27% 28.6% 29.6% 37.3%

  8. PIAA Data Sharing Project • Who • 21 US PLI companies • What • Collects data on closed claims-1985-2007 • When • Puts out semi annual reports • Why • Provide statistical data re: PLI to members

  9. Indemnity payments by specialty PIAA Data Sharing System Report 082 Ob/Gyn • #1 for total claims reported • #1 for percentage of paid claims/total claims • 35.2% • 5.7% more than any other specialty • #1 for total indemnity paid

  10. Four top conditions/procedures for number of paid claims Account for over $9 billion paid Over 35% of dollars paid out of top 40 Brain damaged infant Breast cancer Pregnancy Acute myocardial infarction PIAA Data Sharing System Report 082

  11. Four top conditions/procedures for total indemnity dollars paid PIAA Data Sharing System Report 082 Brain damaged baby Breast cancer Pregnancy Symptoms of abdomen and pelvis

  12. COPIC data (15+YRS) By Error/site type 49% conduct in L&D setting 26% conduct related to technical performance and complications of GYN surgery 21% conduct related to diagnosis and treatment of non-obstetrical conditions, usually in the office setting 5% conduct directly related to prenatal care

  13. COPIC data (15+YRS) 49% conduct in L&D setting • Neurologically impaired infants • Improper interpretation of FHR tracing • Failure to respond to abnormal FHR tracing in a timely manner • Complications of VBAC • Complications of operative vaginal delivery

  14. COPIC data (15+YRS) 26% conduct related to technical performance and complications of GYN surgery Bowel / bladder/ureteral injury Sepsis/ post-op infection / abscess Unexpected/poor outcome Lack of adequate indication for elective surgery

  15. COPIC data (15+YRS) 21% conduct related to diagnosis and treatment of non-obstetrical conditions, usually in the office setting Delayed DX of cancer Breast, Cervix, Ovary, Germ cell, Colon, Lung Delayed DX of MI, PE, Intracranial Tragedies Delayed DX of Severe Infectious Diseases Medication Errors

  16. COPIC data (15+YRS) 5% conduct directly related to prenatal care antenatal DX of fetal abnormalities genetic screening group B strep prematurity management The defense of L&D adverse outcomes often points to the prenatal record

  17. OB-GYN risks summarized • Most claims involve elements of communication or information breakdown • Many claims could have a causation defense, but the necessary elements were missing or not documented 18

  18. Prevention • Standardized Communication • Online EFM Course • Team Training • Disaster Training/Drills • Simulation 19

  19. Defense • ACOG neonatal encephalopathy guidelines and suggestions for practice • Proper documentation • Gather clinical evidence for timing 20

  20. COPIC patient safety initiatives OB Patient safety/RM seminar Team work Common language Disaster drills Simulation Checklists Standard orders

  21. Checklists • Monitoring • oxytocin • magnesium sulfate • misoprostol • Other high risk medications • Documentation • Shoulder dystocia • Operative vaginal delivery These are available atwww.callcopic.com

  22. What do the checklists do for us? • Make explicit the minimum expected steps in a complex system • Help memory recall • Provide a conservative, “default” mode of management which will be carried out in the absence of our specific order to the contrary in a specific patient. • Used in this manner, it is much more difficult for a patient to be injured by these medications. 24

  23. Patient safety toolkit Keep the patient and family informed Workup an unhealthy baby early Document, Document, Document Honest disclosure to patient and family when problems occur Keep the lines of communication open with patient and family before and after discharge

  24. The best way to prevent being sued • Prevention of the problem from occurring in the 1st place • Thus patient safety is the lynchpin of risk management • But sometimes adverse outcomes occur despite perfect care 26

  25. The Science Officially endorsed by: CDC Child Neurology Society March of Dimes NICHD Royal Australian and NZ College of Ob/Gyn SMFM Society of Ob/Gyn of Canada January2003

  26. NNE 25% Antepartum and intrapartum risks 4% Intrapartum hypoxia only 69% Antepartum risks 2% No identified risk factors

  27. Are Obstetricians an Endangered Species? • There is currently no proven way to reduce the incidence • of cerebral palsy in most cases • Obstetricians can expect to be sued approximately once • every 10 years • Reimbursement is relatively fixed • Practitioners are leaving early at one end of the pipeline, • and fewer students are entering training at the other end

  28. Effects of Liability: Changes in Practice‡ Among Respondents Who Have Practiced Obstetrics Between 1995 and 2006* CGOS 2006 survey data of OB providers in CO • Accepted fewer public aid patients: 182 (26%) • Accepted fewer high-risk patients: 153(22%) • Performed more ultrasounds: 236 (33%) • Performed more Cesarean sections: 203(29%) • Stopped performing VBACs: 187 (26%) • Reduced salaries (of physicians/staff): 217 (31%) • Delayed upgrading office equipment: 145(20%) • Stopped practicing obstetrics: 99(14%) • Stopped practicing obstetrics or retired from practice:110 (15%) ‡ Changes specifically due to liability insurance costs or liability pressure *N=711

  29. Access to Obstetrical Care ‡ Numbers and percentages are based on birth data collected for the year 2006 by the Colorado Department of Public Health and Environment. § Counties with 16 or more births per month per obstetrical care provider. CGOS 2006 survey data of OB providers in CO

  30. Do Rising Costs Affect Access? CGOS 2006 survey data of OB providers in CO

  31. Thank you “It has never been safer to have a baby and never more dangerous to be an obstetrician.” Questions? MacLennan et al: JAMA 2005;294:1688-1690 Alethia (Lee) Morgan, M.D.LMorgan@copic.com www.callcopic.com

  32. 2007 FP $13,544 OB/Gyn $54,545 FP $ 60,402 OB/Gyn $275,466 17 25 8 8

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