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Better Outcome? Better Prep.


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Better Outcome? Better Prep.

By Tom A. Augello, CRICO

Related to: Communication, Obstetrics, Teamwork Training

Assuming everything will go well is less safe than being prepared for the worst.


  • David Acker, MD; Brigham and Women’s Hospital; Boston, MA


The following case abstract is based on closed claims in the Harvard system. Names and some details have been changed.

In this case, the facts suggest that a serious adverse outcome might be prevented by preparing for the worst, rather than expecting everything will go well.

Janet Levine’s second pregnancy was uncomplicated, except that she was carrying  twins and the uppermost co-twin was in a breech presentation. Ms. Levine planned with Dr. Jennings, her OB/Gyn, to deliver her twins at a community hospital. They scheduled an induction, and the first twin was delivered vaginally, without difficulty.

When Dr. Jennings encountered problems delivering the second twin, he re-confirmed that it was still a breech presentation. During an attempt to turn the baby, the membranes ruptured. The umbilical cord was wrapped around the baby’s feet and lower body. Dr. Jennings continued with attempts to re-position the baby head-first for a vaginal delivery. When the cervix contracted on his hand, he called for the anesthesiologist to administer nitrous oxide to relax the uterus for further attempts to reposition the baby.

The room did not have an ultrasound machine, and the nurse monitored the baby’s heart rate with a hand held device. At one point the heart rate dropped to 43 beats per minute, but Dr. Jennings believed delivery was imminent. More time passed without successful vaginal delivery and so, he eventually called for a C-section.

The baby was born with very low Apgars. The infant had no gag reflex, and an EEG demonstrated severe brain damage. The baby was diagnosed with spastic quadriplegia and was blind and deaf  prior to her death nearly six months later.

The parents sued Dr. Jennings, alleging negligent delays in delivery and treatment of fetal distress. The plaintiff’s expert witness had to be replaced less than two weeks before trial. Expert reviews for the defense were mixed. But the defense team believed it could prevail at trial with an effective defendant and expert witness. The jury returned a verdict for the defense.

To discuss the risk management and patient safety aspects of this case, Resource speaks with Dr. David Acker. Dr. Acker is Chief of Obstetrics at Brigham and Women’s Hospital in Boston.

What are some of the top-level lessons that almost anyone in any specialty could learn from what happened in this case?

So we “won” and the mother and the baby lost. Somehow conscientious people, once we got over being happy winning, probably sat back and said there is no winning when there is a harmed baby and a family that will probably never recover from this…. I think the top-level lesson is to plan ahead. And there are two different view of planning ahead: the view could be that things usually work out well. In addition to that, when they don’t work out well, there usually is a means to extricate the baby, the mother and the doctor from the situation where things have not worked out well. If you focus your attention on what is most likely to occur, what a reasonable person would do, then in many respects you satisfy the requirements of the law and that’s good, but you miss out on the opportunity to go one level beyond that and that is to prepare for the worst case scenario.  …I think the thing that I learned as I reviewed this case was that there were system, basically system, approaches that would have led to a better outcome for the family and the baby.

How so; what’s an example?

In this particular case, the surveillance instruments were not brought into the operating room.  Just think of a simple policy.  No one really has to ever ask for the surveillance instruments.  The hospital buys an ultrasound machine and a fetal monitor, and it lives in the corridor near the operating room.  It’s there.  When you are going back for a twin delivery, you bring it right in.  No one asks. That way no one forgets or no one thinks well, my last five cases went well, I don’t need it now.  It’s right there.  ... I can’t know for sure that with the use of these surveillance instruments whether that might have been avoided or not, but as a general rule, apart and aside from this specific case, having those instruments there is better than having them somewhere else at that time…
A number of specialties, obstetrics in particular, are looking to team training as a way to improve outcomes; team training brought into healthcare from other high-risk industries, focusing on training junior staff to raise concerns with superiors, communicating reliably, backing each other up: is this team method  also a way to be better prepared for something to go wrong?

Well, I can’t predict specifically what team training would have done for this case.  I can only give you a point of view of what I think team training accomplishes.  I think the major attribute of team training is communication between various health care professionals on a level playing field. …I would think that team training would have led to Doctor A saying I’m going back for a head-first, non head-first twin delivery. Doctor B would have said I’m going with you, not because you’re incompetent but because our system has set up a schedule that today’s my day to accompany twin deliveries.  It is my day to be back there when the blood loss is more than 1000 cc. This is my day to be the helper, not because you have been singled out as needing it but because we are here to help each other.

It’s the type of thing that can go anything from a polite knock on the door with an offer to help to a more firm statement, ‘I think you need help,’ and in between all of the in betweens of professional behavior fall. We think that it is better to intervene on the patient’s behalf than to observe possibly 19th century hallmarks of genteel behavior.

There is a “reasonableness” issue that is embedded in every legal case.  It seems that in this case, it played a bigger role for the jury. The definition of ‘reasonable’ is elusive isn’t it?

Well, I think the law and medicine have left it that way knowing how hard it is to judge judgment.  So we’re asked to merely ask the physician to behave as other reasonable physicians would, not like the best physician on the block but not like the worst. If you are in between there and a jury can fulfill its obligations to not be too angry with you and to judge you that way, then from a medical/legal aspect, we “win.” There is more to obstetrics than winning the case. We would like to have the smallest number of preventable injuries to babies occur. Then we will also win medically/legally and we’ll win medically.

May 1, 2006
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