A Practical Guide to Third Trimester of Pregnancy and Puerperium Alok Sharma
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1Anatomy and Physiology2

Obstetrics Risk ManagementCHAPTER 1

Savita R Singhal,
Roopa Malik
 
INTRODUCTION
Patient safety is our prime concern, particularly when it is an obstetric patient where two lives are involved. There is need of 100% perfection on the part of the healthcare providers, as slight negligence can be a nightmare for patient, family, society, and physician. Since the inception of patient safety concept in 1991, there has been surge in publications on obstetric risk management.
Risk management is the identification, assessment, and prioritization of risk followed by application of resources to minimize and control the occurrence and impact of unfortunate events or to maximize the realization of opportunities.1 Healthcare staff does not have any intention to harm the patients, in spite of their efforts for patient safety, risks occur in health sector due to medical negligence. There is risk to physician also is in the form of financial loss due to litigation, damage to morale and reputation and about 38% of doctors who are sued suffer from depression.2 A study at Institute of Medicine, United States (US), reported 44,000–98,000 deaths each year in hospitals as a result of medical errors.3 The medical negligence is on increase in recent years and cost has almost doubled in United Kingdom (UK), overall expenditure in 1998 was 84 million dollars.4 Risks in the field of obstetrics are much more as clinical situation can change rapidly, especially during intra- and postpartum periods. As per National Health Survey Litigation Authority, 2012, 49% of total values of claims were for the obstetric speciality.5 Many obstetricians are abandoning their practice because of higher liability risks, especially in western countries.
 
TYPES OF RISKS
The risks can be classified broadly into two types:
  1. Nonclinical risks
  2. Clinical risks.
 
Nonclinical Risks
Nonclinical risks have least to do with the clinical acumen of the physician and are mainly at the administration level, due to system/equipment failure. Few examples are:
  • Shortage of supplies
  • Faulty equipment and machinery
  • Falling of patient from a trolley
  • Hazard due to electricity supply failure
  • Baby delivering in toilet commode
  • Delay in shifting of patient to operation theater
  • Delay in cesarean due to large number of pending emergency cases.
 
Clinical Risks
The clinical risks are most of the times due to errors at the level of treating physician and team. The errors can be categorized as:
  • Intentional errors: These errors are due to:
    • Violation of rules or guidelines
    • As an act of omission
    • Due to lack of knowledge
  • Unintentional errors: These errors are mostly due to:
    • Overburden of work, fatigue4
    • Misinterpretation of clinical findings
    • Incorrect history by patient
    • Incorrect or partial information at time of patient handoff.
Clinical risks are like if proper consent is not taken, unnecessary cesarean section, incorrect decision regarding obstetric hysterectomy, etc.
 
OBSTETRIC RISK EVENTS
The common risks events to mother and newborn are:
  • Neonatal risks:
    • Birth asphyxia
    • Birth trauma
    • Admission to neonatal intensive care unit (NICU)
    • Fresh still birth
    • Early neonatal death
  • Maternal risks: it can occur during antenatal, intra- or postpartum periods
    • Antenatal period:
      • Failure to diagnose thalassemia, heart disease, congenital malformation or malpresentation
      • Maternal morbidity (shifted to intensive care unit, renal failure)
      • Eclampsia in hospitalized patient
      • Scar rupture or uterine rupture
    • Intrapartum period:
      • Prolonged or difficult delivery
      • Inappropriate use of vacuum or forceps
      • Shoulder dystocia
    • Postpartum period:
      • Venous thromboembolism
      • Retained foreign body, swabs, etc.
      • Postpartum hemorrhage
      • Maternal death.
 
CAUSES OF OBSTETRIC RISK EVENTS
The risks are due to many factors listed below.
 
Communication Lapses
Communication failures are one of the leading causes of medical errors and as per the Joint Commission on Accreditation of Healthcare Organizations, 72% of obstetric adverse events are due to poor communication.6 Physician ability to communicate with the patient and among team members is the key for patient safety. Lapses in communication may be due to excessive hierarchy as seen in teaching hospitals, improper intimidation, language barrier, physical environment, and lack of structured communication. Communication lapses can occur at various levels.
 
Patient-physician Communication
Patient outcome depends a lot on successful communication with the patient. With good communication, especially if it is in her language, patient develops rapport and trust in physician and can come out with certain facts which may help in arriving at correct diagnosis and counseling the patient regarding treatment plan and prognosis. There are various communication models; to discuss all is beyond the scope of this chapter. Few are listed below:
  • Partnership model: It is a type of open communication in which physician and patient spend equal time with each other in talking and thus increases patient involvement in healthcare through counseling, in treatment plan, and long-term follow-up.7 This model helps in reducing the likelihood of litigation
  • Acknowledge, Introduce, Duration, Explanation and Thank You model: This model is developed by Studer Group8 and it comprises: to acknowledge the patient, give your introduction, give reasonable time, explain properly to the patient, and show appreciation for her cooperation
  • Rapport, Empathy, Support, Partnership, Explanation, Cultured background, and Trust model: It has seven components: rapport, empathy, support, partnership, explanation, cultured background, and trust.9
 
Physician-physician Communication
Communication of information about patient from one member of healthcare team to another is critical part of patient safety. Structured form of communication, such as Situation, Background, Assessment and Recommendation technique,10 should be considered. The process includes the interactive communication, limited interruptions, a process for verification, an opportunity to review a relevant data, and discussion between the giver and receiver of the patient's information.
 
Incomplete Documentation and Record Keeping
Records are the documents or other things that preserve the information and record keeping is an important tool to improve the quality of patient care. Some physicians feel that record keeping is onerous task that prevent them from providing care to patient rather they should remember that it is a key element and is part of professional duty. Electronic health record (EHR) is better than paper health records as EHR has the advantage of improving legibility of prescription, reducing the risk of medication errors, and online accessing of information.11
Important points regarding documentations are as follows:
  • Entries should be legible
  • Entries should be signed with physician's full name and job title5
  • Records should be complete, e.g., partogram, labor charts, delivery, operation notes
  • If any amendment or alteration is required than that should be done without defacing the original entry which should be readable and the amendments are to be signed by physician with name and title
  • Always write the accurate time and dates of findings
  • Use standard abbreviations
  • Always mention the indication of surgery in operative notes
  • Notes should be written by physician who is delivering the care
  • Records should be completed as early as possible after the care.
 
Improper Consent
Informed consent is the process of communication between patient and physician that results in the patient's authorization or agreement to undergo a specific medical intervention and the patient must be fully informed in her language before decision to undergo major treatment and it must be documented in written.12 It has two components:
  1. Comprehension
  2. Free consent.
Comprehension: It includes patient's awareness, understanding of situation and possibilities, meaning she has been given all options of treatment and prognosis in her own language.
Free consent: It is voluntary choice to authorize someone else to act in certain ways.
In India, sometimes it is seen that the physician gets the consent signed from husband or mother-in-law or any other relative of the patient, but for legal purposes, the consent has to be signed by patient herself before any procedure or treatment. Proxy consent is allowed only in certain situations where patient is not in a position to give the consent due to emergency situation (very sick), not mentally sound or underage.
 
Fear, Language, and Culture
Atmosphere of trust should be created in the team to avoid the fear among junior members of team. A line must be drawn between acceptable and unacceptable behaviors. One physician should be held responsible for management and he should be easily accessible. In case of nonavailability, a backup person should be identified. Every member of the team should be encouraged to participate and contribute, to transfer of information without reluctance at time of patient handoff. Using standardized medical terminology avoids errors in communication that may occur when colloquialisms are used. The culture of misbehavior with patient and use of abbreviations, other than those that are well known and widely accepted, should be discouraged. Some of the patients may file a complaint against the treating physician regarding misbehavior or delay in examining and providing treatment, which can be tackled by quality care maintaining the standards.
 
Medication Risk
The incidence of adverse drugs-related injuries varies from 15 to 18.5%.13,14 The medication risk can be in the form of wrong prescription, dosage and route of administration, omission of the drug or administration of expired drug. Most of the errors occur at the level of ordering the drug and are due to fatigue, stress, lack of knowledge, carelessness, illegible handwriting or inappropriate abbreviations used in prescription. Medication risk can be avoided to some extent by:
  • Regular updating of the knowledge regarding dosage and route of administration, contraindications, and interaction with other drugs
  • Reconfirmation of name and date of expiry of the drug at the time of administration by nursing staff
  • Prescription should be legible, clearly mentioning the dosage, route of administration, and frequency of administration. Clear verbal instruction should be given to the patient regarding how and when to take the medicine and also about interaction with other drugs
  • There should be separate boxes for the commonly used, uncommonly used or lifesaving medications to avoid wrong administration.
 
Fatigue
Inadequate sleep and long working hours result in fatigue which can decrease alertness, affect cognitive function, short-term memory, and impair performance. An adult needs minimal of 5 hours sleep at night. As obstetrics is a busy branch with continuous emergency input, the question is for how many hour the residents can work at a stretch. The Accreditation Council for Graduate Medical Education has suggested 16 hours daily work for first year residents and intermediate level and senior residents may be scheduled for 24 hours of duty.15 To avoid the errors due to fatigue, there should be back up care in the department. Secondly, the tasks can be postponed if feasible and can be done at a later time. Work efficiency can be increased by altering sleep pattern like going to sleep immediately after night shift, sleep for 2 hours before night shift or if not possible, then a small nap of 45 minutes can help.
 
Failure to Disclose
Adverse events are unpleasant situation for patient, her family, and the physician, however, timely disclosure of 6adverse events helps in combating the obstetrics risk. It should be done preferably by the senior member and in the presence of minimum of two team members. Disclosure should be timely in the sense that even if all facts are not available, counsel the attendants that further information will be provided soon. Disclosure should be done at a quiet and confidential setting.16 It is important that at the time of disclosure, there should be expression of sympathy, apology, and showing concerns regarding the situation of the women. Some developed countries have reported drastic decrease in the legal fees and liability statement when disclosure programs were followed. University of Michigan Health System and Illinois Medical Center at Chicago noticed 50% reduction in legal fees and actions17,18 once they started following the disclosure programs.
 
Incomplete Patient Handoff
Patient handoff is a necessary component of risk management and is described as the transfer of patient information and knowledge, along with authority and responsibility from one clinician or team of clinicians to another clinician or team of clinicians during transition of care across the continuum. It should include opportunity to ask questions, clarify and confirm the information being transmitted. Every member of the healthcare team should be encouraged to participate and contribute to the transfer of information without hesitation.19 Patient handoff should take priority over all the duties except emergencies.20 Patient handoffs should be complete, clear, and timely and it can be verbal, written or both. Written is always better for documentation purpose. Use of “CUS” words to alert the receiver to level of concern regarding the safety of patient is very important.
  • C: I am concerned
  • U: I am uncomfortable
  • S: I am scared.
 
Machinery and Equipment Failures
In many instances inadequate instructions or poorly designed equipment/machinery like infusion pumps, monitors, cardiotocography machine, etc. can be underlying cause of patient injury. In such cases, it is often assumed that healthcare provider has made an error but on complete root cause analysis (RCA), technical failures may be revealed as a cause of adverse event.
 
Administrative Failures
Inadequate administrative policies guiding the delivery of care can be a significant contributing factor in many medical errors. There may be insufficient supplies of drugs, catheters, intravenous sets, etc. leading to delay in treatment and risk to mother. In India, under various schemes run by Government, e.g., Janani Suraksha Yojana (JSY), Janani-Shishu Suraksha Karyakram (JSSK), there is provision of free treatment and free transport to all obstetrics patients, sometimes there may be delay in procurement of the supplies. There is need of strong transport system both for the patients and healthcare personnel to avoid delay in treatment. Organization is also responsible to provide the training about the assigned work to the healthcare providers, especially where new or temporary employees are often used, so as to orient them to the working place and policies of the institute. There may be lack of organizational transfer of knowledge.
 
PRINCIPLES OF RISK MANAGEMENT
The principles are:
  • Patient safety and quality care
  • Learn from mistakes
  • Develop strategies and guidelines
  • Support for staff members.
The aim of risk management is to reduce the harm to the patient by providing safe and quality care which indirectly safeguards the physician from litigation and enquiries. The policy should be not to blame someone but to learn from the mistakes and to make some rules/guidelines so that risk can be avoided, minimized or eliminated in future. Medical staff should be provided with financial and legal support by the administration.
 
COMPONENTS OF RISK MANAGEMENT
Components of risk management are:
  • Risk reporting
  • Evaluation of risk events
  • Audit of risk events
  • Learning from adverse events
  • Formulating guidelines
  • Funding the risk
  • Risk management tools.
 
Risk Reporting
The risk event can be reported either from a maternity service or from an external source like a national audit. It involves identification of risk after it has happened and list of such events should be maintained and regularly updated by the medical staff. These risk incidents should be well displayed on the maternity dashboards and such events should be reported to risk management team of the hospital without any delay.
 
Evaluation of Risk Events
The risk events can be evaluated prospectively or retrospectively.7
 
Prospective Risk Evaluation
One of the tools for prospective evaluation of risk events is Failure Mode and Effect Analysis (FMEA). In this, any process is outlined in detail and evaluation is done about the ways in which any step might go wrong (failure modes) and consequences of these failure modes. Contributory factors and controls for each failure modes are also identified. Then, action plan is made keeping in mind priorities of each failure mode.
 
Retrospective Risk Evaluation
Once a risk event has already happened, a systemic approach for investigation and identification of contributory factors and ways to prevent its recurrence is known as RCA. It is well accepted method. There should be regular staff clinical meetings on maternal mortality or near miss or other adverse events to evaluate the risks.
 
Audit of Risk Events
Audit of risk events can be done at the regional level from where the risk has been reported or at higher level, e.g., national level. Audit should include the entire important adverse event reporting, the effectiveness and implementation of formulated guidelines and re-audit to make sure the action has had the desired effects, e.g., in UK, there are national audits related to obstetric field most important being Confidential Enquiry into Maternal and Child Health. The reports of these audits are used as a reference for source of learning and service review.
 
Learning from Adverse Events
This involves sharing of lessons learnt from risk analysis and treatment with other staff members at local level or at a broader level like national level so as to prevent its recurrence. It is also beneficial to the patient and their attendants so as to understand why risk event happened.
 
Formulating Guidelines
It means to prepare guidelines or policies to decrease the chances of risk happening again and also to limit the damage as a result of risk event which has already occurred. Guidelines may involve providing the orientation and training programs to medical staff, improving infrastructure or manpower. It also includes making protocols for the treatment according to availability of resources and acceptability by the concerned population.
 
Funding the Risk
There should be some financial support policies by the administration to the affected healthcare providers and sufferer. Administration may also provide medicolegal help to the staff members. Various schemes have been launched in UK to combat these financial claims like Clinical Negligence Scheme Trust, Existing Liabilities Scheme, Liabilities to Third Party Scheme, etc.
 
Risk Management Tools
Various tools have been devised for management of risks, like:
  • Checklist: As humans have limited ability to remember, well designed checklists are very effective in reducing the risk. These are only effective if they are used every time you perform any specific procedure, even if you are fully trained and experienced. The World Health Organization has provided pilot edition of the Safe Childbirth Checklist to support the delivery of essential maternal and perinatal care practices
  • Risk management and standard operating procedures: It includes use of various risk management tools, like checklist, communication strategies (closed loop, read back, repeat back), briefings, debriefings, and standard operating procedures for correct use of each procedure
  • Nontechnical skills (NOTECHS): NOTECHS is a behavior rating system that allows valid and reliable observation and assessment of various NOTECHS of operating team; surgeon, anesthetist, and nursing staff.21 The skills which are assessed are as follows:
    • Vigilance and situation awareness:
      • Developing and maintaining a dynamic awareness of the situation in theater based on assembling data from the environment (patient, team, time, displays, equipment), understanding what they mean, and thinking ahead about what may happen next
      • Gathering information
      • Understanding information
      • Projecting and anticipating future state
    • Decision making during surgical crisis:
      • Skills for diagnosing the situation and reaching a judgment in order to choose an appropriate course of action
      • Considering options
      • Selecting and communicating option
      • Implementing and reviewing decisions
    • Communication and interaction:
      • Skills for working in a team context to ensure that the team has an acceptable shared picture of the situation and can complete tasks effectively
      • Exchanging information
      • Establishing a shared understanding
      • Coordinating team activities
    • Leadership and management skills:
      • Leading the team and providing direction, demonstrating high standards of clinical practice 8and care, and being considerate about the needs of individual team members
      • Setting and maintaining standards
      • Supporting others
      • Coping with pressure
  • Patient safety programs: Patient safety programs help in combating the medical liabilities and such programs may be developed at level of the institute as per requirement. In UK, National Patient Safety Agency22 was established in 2001 and US, Australia, and other countries have also set standards, training, and research on issue of patient safety. In one study at New York Presbyterian Hospital, implementation of patient safety programs reduced the compensation from 27 million dollars in 2003–06 to 2.5 million dollars in 2007–09 and sentinel events decreased from 5/1,000 in year 2000 to none in 2008–09.23
 
OBSTETRIC RISK PREVENTION AT DIFFERENT LEVELS
Various steps can be taken at different levels to prevent the risk events in obstetrics.
  • Administrative level:
    • Proper and sufficient supply of good quality drugs, equipments, machinery
    • Adequate infrastructure
    • Adequate number of experienced staff
    • Training of staff: Staff should be sent on regular trainings, workshops, and conferences for updating their knowledge of subject
    • Making teams for regular supervision
    • Strong transport system
  • Departmental level:
    • Coordination between staff members
    • Assignment of duties, especially for teaching hospitals where multiple levels of working staff is there, so as to fix the responsibility
    • Protocol and guidelines should be issued for management of common clinical conditions
    • Protocols to be displayed in labor wards and emergency
    • Time-to-time staff clinical meetings for discussion of adverse events and mortality
    • Back up for the medical staff in case of emergency due to fatigue, overwork or personnel problems
  • Treating team level:
    • Coordination between team members
    • Take written informed consent from the patient
    • Give all treatment options to the patient, let the patient decide about the management
    • Follow the protocols designed in the department
    • If referral needed, early referral is advisable to decrease the morbidity and mortality
    • Complete and proper record keeping should be done by members of treating team with legible signatures
    • Handoff of the patients at the time of change of duties with complete records of the patient
    • Timely disclosure of adverse events
  • Individual level:
    • Updating knowledge regularly, by reorientation programs, from internet and journals
    • While communicating with the patient, be polite, explain in detail about the procedure, effects, and side effects of treatment
    • Do not hesitate to take consultation of senior personnel if in doubt
    • Do not be negligent in examining the patient at admission and during care
    • Read literature or watch video before doing any procedure, if not confident
    • Avoid doing duties when fatigued; ask for change of the duties.
 
EMERGENCY SITUATIONS IN OBSTETRICS
Various obstetric emergency situations, such as postpartum hemorrhage, fetal distress, cord prolapse, shoulder dystocia, eclampsia, and many more, are seen in day-to-day practice. Emergency management in obstetrics is very crucial as most of the mortality and morbidity occurs during the emergencies. For handling the emergencies, there is need for adequate number of trained staff, drug supplies, and equipments. To deal with emergency situations and to decrease the risk events, there is need of:
  • Protocols: the protocols should be put in labor room, patient-receiving room or casualty
  • Emergency drills and simulation: this is the need of the hour, especially for the hospitals with less working load or frequent change of the supporting staff
  • Crash cart: it is important to see that there is adequate number of drugs and it has to be replenished and rechecked periodically for expiry date of the drugs by nursing staff
  • Trigger points: department can make some protocols of trigger points and paste it, so that even lower staff can inform when trigger threshold limits are crossed
  • Adequate supplies: depending on the workload of the hospital
  • Rapid response team: recently, the concept of rapid response team is promoted by various societies like the American Congress of Obstetricians and Gynecologists, Joint Commission, and Association of Women's Health.24
    The rapid response team has four components:
    1. Activators
    2. Responders
    3. Quality improvement
    4. Administrator.
Activators are individuals who activate the rapid response team and these may be clinical staff, floor staff, or nursing staff or even the clinicians. Responders are 9the clinicians who attend the patient and provide the treatment. The quality improvement team reviews the activators and responders, and makes recommendations which are implemented by administrators.
 
Example
A 28-year-old G2P1L1 woman with 39 weeks pregnancy reported to emergency with chief complaints of labor pains for past 2 hours. She was examined by the junior resident and was kept for vaginal delivery. Later on, she had decelerations and emergency cesarean section was done in view of fetal distress. A baby of birth weight 4.2 kg was delivered with an Appearance, Pulse, Grimace, Activity, and Respiration/American Pediatric Gross Assessment Record (APGAR) score of 3/10 at birth. Retrospectively, she gave history of gestational diabetes which was managed on diet. The baby was admitted to NICU because of severe birth asphyxia. After a stay of 7 days in NICU, baby expired. Patient filed a legal suit against the hospital for mismanagement.
 
What do we Learn from this Example?
  • The decision for mode of delivery should have been taken by the senior obstetrician as the resident might not have enough knowledge to decide the mode of delivery
  • Incomplete history taking: there should have been proper communication with the patient giving adequate time so that she would have given history of gestational diabetes at the time of admission only
  • Informed written consent should be obtained regarding the risk of big size baby, gestational diabetes, chances of having fetal distress and its consequences, which could help at time of litigation.
 
CONCLUSION
Patient safety and quality care is the key factor for risk management. There should be policy of learning from mistakes and not to blame. Adequate supplies, manpower, and infrastructure should be ensured. Staff should be sent on regular trainings, workshops, and conferences for updating their knowledge of subject. Proper communication with patient and among team members is very important. Informed written consent should be taken from the patient. Departmental protocols should be formulated and followed strictly. Patient handoff should take priority over all the duties except emergencies. Risk events should be reported to seniors. Existing policies should be reviewed and new guidelines should be formulated. Medical staff should be provided with financial and legal support by the administration in case of adverse events.
REFERENCES
  1. Hubbard WD. How do we know what works? In: The Failure of Risk Management: Why It's Broken and How to Fix It. Hoboken, NJ, John Wiley and Sons;  2009. pp. 37–46.
  1. Scholefield H. Risk management in obstetrics. Curr Obstet Gynaecol. 2005;15:237–43.
  1. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study 1. N Eng J Med. 1991;324(6):370–6.
  1. Fenn P, Diacon S, Gray A, Hodges R, Rickman N. Current cost of medical negligence in NHS hospitals: analysis of claims database. BMJ. 2000;320(7249):1567–71.
  1. NHS Litigation Authority. (2012). Ten Years of Maternity Claims: An Analysis of NHS Litigation Authority Data. [online] Available from www.nhsla.com/Safety/Documents/Ten%20Years%20of%20Maternity%20Claims%20-%20An%20Analysis%20of%20the%20NHS%20LA%20Data%20-%20October%202012.pdf. [Accessed May, 2015].
  1. The Joint Commission on Accreditation of Healthcare Organizations. (2004). Sentinel Event Alert, Issue 30: Preventing infant death and injury during delivery. [online] Available from www.jointcommission.org/sentinel_event_alert_issue_30_preventing_infant_death_and_injury_during_delivery/default.aspx. [Accessed May, 2015].
  1. Roter DL. Patient question asking in physician-patient interaction. Health Psychol. 1984;3(5):395–409.
  1. Studer Group. Acknowledge, Introduce, Duration, Explanation, and Thank You (AIDET®): Five Fundamentals of Patient Communication. AIDET Implementation Guide. Gulf Breeze, FL, United States of America: Studer Group; 2005.
  1. Mutha S, Allen C, Welch M. Toward Culturally Competent Care: A Toolbox for Teaching Communication Strategies. San Francisco, CA, United States of America: Center for the Health Professions, University of California;  2002.
  1. Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf. 2006;32(3):167–75.
  1. Committee opinion no. 472: Patient safety and the electronic health record. Obstet Gynecol. 2010;116(5):1245–7.
  1. ACOG Committee on Ethics. ACOG Committee Opinion No. 439: Informed consent. Obstet Gynecol. 2009;114(2 Pt 1):401–8.
  1. Hug BL, Witkowski DJ, Sox CM, Keohane CA, Seger DL, Yoon C, et al. Adverse drug event rates in six community hospitals and potential impact of computerized physician order entry for prevention. J Gen Int Med. 2010;25(1):31–8.
  1. Landrigan CD, Parry GJ, Bones CB, Hackbarth AD, Goldman DA, Sharek PJ. Temporal trends in rates of patient harm resulting from medical care. N Eng J Med. 2010;363(22):2124–34.
  1. Nasca TJ, Day SH, Amis ES, ACGME Duty Hour Task Force. The new recommendations on duty hours from the ACGME Task Force. N Eng J Med. 2010;363(2):e3.
  1. Weiss PM, Miranda F. Transparency, apology and disclosure of adverse outcomes. Obstet Gynecol Clin North Am. 2008;35(1):53–62.
  1. Boothman RC, Blackwell AC, Campbell DA, Commiskey E, Anderson S. A better approach to medical malpractice claims? The University of Michigan experience. J Health Lit Sci Law. 2009;2(2):125–59.

  1. 10 McDonald TB, Helmchen LA, Smith KM, Centomani N, Guvderson A, Mayer D, et al. Responding to patient safety incidents: the “seven pillars”. Qual Saf Health Care. 2010;19(6):e11.
  1. ACOG Committee Opinion No. 517: Communication strategies for patient handoff. Obstet Gynecol. 2012;119(2 Pt 1):408–11.
  1. William RG, Silverman R, Schwind C, Fortune JB, Sutyak J, Horvath KD, et al. Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care. Ann Surg. 2007;245(2):159–69.
  1. Mishra A, Catchpole K, McCulloch P. The Oxford NOTECHS System: reliability and validity of a tool for measuring teamwork behaviour in the operating theatre. Qual Saf Health Care. 2009;18(2):104–8.
  1. NHS National Patient Safety Agency (NPSA). (2001). Transfer of Patient Safety function to the NHS Commissioning Board Special Health Authority. [online] Available from www.npsa.nhs.uk. [Accessed May, 2015].
  1. Grunebaum A, Chervenak F, Shupski D. Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events. Am J Obstet Gynecol. 2011;204(2):97–105.
  1. American College of Obstetrician and Gynecologists Committee on Patient Safety and Quality Improvement. Committee opinion no. 590: preparing for clinical emergencies in obstetrics and gynecology. Obstet Gynecol. 2014;123(3):722–5.