Postpartum Malpractice Claims: Can We Understand Preventable Harms and Socioeconomic Factors?

Quarterly Closed Claims Study from The Doctors Company with David L. Feldman, MD, Chief Medical Officer

By David L. Feldman, MD, MBA, Jacqueline Ross, PhD, RN, and Shelise Valentine, RNC, MSN

Rates for maternal morbidity and mortality are higher in the U.S. than in any other developed country —and many of the harms suffered by patients are preventable. In a multifactorial study, The Doctors Company investigated postpartum claims to develop clinical recommendations to decrease the risks of postpartum morbidity and mortality.

Investigators reviewed 43 closed postpartum medical malpractice claims dating to incidents from 2015 to 2020, with the postpartum period defined as birth through 90 days post-discharge. Data was extracted using the Candello Comprehensive Risk Intelligence Tool and Advanced Report Writer tool. Researchers investigated factors present in postpartum claims, indicators of severe maternal morbidity, and socioeconomic factors.

Indicators of severe maternal morbidity included: Blood product transfusion, hysterectomy, cardiac arrest / ventricular fibrillation, disseminated intravascular coagulation, hemorrhage, sepsis, ventilation, shock, amniotic fluid embolism, and eclampsia.

Analyzing medical malpractice claims that arise out of recurring, preventable sources of risk can aid medical professionals and institutions in identifying and adhering to best practices for care.

Tips for Malpractice Risk Reduction: Dr. Feldman’s 3 Ps

More than half of the claims studied were determined to have been preventable, and common themes emerged.

1. Prevent adverse events:
   1. Follow blood transfusion guidelines. Many of the patients in these claims did not receive adequate blood products, and blood product transfusion was the top severe maternal morbidity indicator among the studied claims.
   2. Remain vigilant for obstetric hemorrhage. Obstetric hemorrhage was found to be a common indicator of severe maternal morbidity. Uterine atony accounts for 70 to 80 percent of obstetric hemorrhages, and if uterine atony is identified early, it can be treated with medication (oxytocin) or fundal massage.
   3. Elevate awareness of risks related to socioeconomic distinctions. Patient harms were unevenly distributed. Limits on information available regarding the patients in closed malpractice claims, together with the smaller scale of this data set, preclude any definitive stratification of patients’ risks. Nevertheless, higher-severity injuries tended to cluster among patients of color and patients with public health insurance or no health insurance.
   4. Adopt a standardized communication system. Delay in treating hemorrhage was often accompanied by poor communication among members of the care team, who missed opportunities to use communication tools like Situation-Background-Assessment-Recommendation. The adoption of a standardized communication system is an opportunity to prevent adverse events.
2. Preclude malpractice claims:
   1. Communicate with patients about potential complications. Identify opportunities to discuss possible complications, especially in high-risk patients, prior to delivery. Document such discussions. Advanced communication may obviate a lawsuit should the complication occur.
3. Prevail in lawsuits:
   1. Capitalize on clear communication in documentation. A communication system can aid in the creation of clear, consistent documentation, because a standardized communication system facilitates the creation of a shared mental model and shared understanding of events among team members. This is easier said than done in the dynamic environment of a labor-and-delivery floor. Still, clear and consistent documentation may prove expeditious if the quality of care is later questioned.
   2. Document the adoption of care bundles. One evidence-based method to improve the process of care and patient outcomes is the use of national patient safety bundles, which are structured and specific to clinical conditions, such as obstetric hemorrhage or severe hypertension in pregnancy. Moreover, the adoption of care bundles signals rigorous adherence to the standard of care, even if a patient should experience a complication or an unfortunate outcome. This could be a critical element in the defense of a lawsuit.

This discussion of postpartum claims is based on “Postpartum Malpractice Claims: Understanding Preventable Harms and Socioeconomic Factors,” published by The Doctors Company.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider, in consideration of the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.