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OB: A Cautionary TaleFrom: art fougner, md (evsono@pipeline.com)Thu Aug 18 07:40:36 2005
>From the 17AUG issue of JAMA ... CLINICIAN’S CORNER A 38-Year-Old Woman With Fetal Loss and Hysterectomy Benjamin P. Sachs, MB, BS, Discussant JAMA. 2005;294:833-840. Mrs W is a married, self-employed, healthy woman living in a community several hours from Boston. She has private health insurance. At age 38, she was admitted to the hospital for elective delivery of her first child, but the admission ended tragically with fetal loss, hysterectomy, and a prolonged hospitalization. The post hoc analysis is timely ... Our analysis concluded that this case involved numerous failures in terms of communication and planning, including 4 errors in judgment. Six system failures were also identified. First, communication was poor ...Second, mutual performance cross-monitoring,9 the concept of a team approach in which another physician or nurse identifies issues and informs the attending physician, was not in place...Third, there was inadequate conflict resolution...Fourth, the team displayed poor situational awareness, in that they did not comprehend the essential elements in Mrs W’s case and anticipate future events based on this understanding...Fifth, the physician workload was too high and there was no contingency plan in place to deal with the overload such as calling for backup and reassigning patients. Sixth, the attending physician had been on call for 21 hours, which may have impaired the physician’s judgment. Regarding work hours ... Although US teaching hospitals have taken serious steps to reduce work hours for residents, similar steps have not been taken for attending physicians, and their jobs may have become more complicated because of reduced resident work hours. At some point, the frequency of call and the volume of patients cared for by any one physician could affect the quality of care. In industrial settings, individuals who work 24 consecutive hours make errors at a rate equivalent to an individual with a blood alcohol level of 0.10%,11 which in most states exceeds the level used to define drunken driving. Interns working more than 24 hours in a row made 36% more serious errors than interns working shorter shifts.12 Future research should examine whether this also applies to attending physicians. Before limiting shift lengths for all physicians, however, the consequences of reduced continuity and need for increased communication among staff should be considered and assessed. Read ... and then reread the whole thing. art
-- art fougner, md
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