Obstetrics

Know your risk: Medico-legal data by clinical specialty

3 minutes

Published: October 2022

The Canadian Medical Protective Association (CMPA) represents over 105,000 physicians and draws experience from its database of over 500,000 medico-legal cases. These cases include civil legal actions, regulatory authority (Colleges), and hospital matters.

As of the end of 2020, 1,702 CMPA members were obstetricians and gynecologists (Type of Work 93). In addition, some family physicians (Type of work 35, 78 and 79) also provided obstetrical care.

This report describes the findings drawn from the 568 civil legal cases, College and hospital matters involving obstetrical care, closed by the CMPA between 2015 and 2019.

What are the most common patient complaints? (n=568)1

Diagnostic errors (51%), Deficient assessment (46%), Failure to perform interventions or tests (46%), Inadequate consent process (24%), Inadequate monitoring or follow-up (21%), Communication breakdown with patient (21%)

  •  Diagnostic errors (51%)
  •  Deficient assessment (46%)
  •  Failure to perform interventions or tests (46%)
  •  Inadequate consent process (24%)
  •  Inadequate monitoring or follow-up (21%)
  •  Communication breakdown with patient (21%)

Complaints are a reflection of the patient’s perception that a problem occurred during care. These complaints are not always supported by peer expert opinion. Peer experts may not be critical of the care provided, or may have criticisms that are not part of the patient allegation.

What are the most frequent interventions and common peer expert criticism associated with them? (n=568)

Intervention frequencies among medico-legal cases are likely representative of physicians’ practice patterns and do not necessarily reflect high risk interventions.

Cesarean section (20%), Electronic fetal monitoring (18%), Operative vaginal delivery with forceps or vacuum (14%), Augmentation of labour (11%), Induced labour (7%)

  •  Cesarean section (20%)
  •  Electronic fetal monitoring (18%)
  •  Operative vaginal delivery with forceps or vacuum (14%)
  •  Augmentation of labour (11%)
  •  Induced labour (7%)

The most common peer expert criticisms on these interventions include:

  • Delay or failure to perform intervention
  • Failure to establish an accurate and timely diagnosis
  • Misinterpretation of fetal heart rate
  • Team communication breakdown
  • Deficient patient history or general evaluation
  • Contraindicated medication or intervention

What are the top factors associated with severe patient harm in medico-legal cases? (n=568)2

Patient factors

  • Advanced age (>35 years)
  • Abnormal fetal heart patterns
  • Obstructed labour

Provider factors3

  • Deficient patient assessment
  • Failure to perform test or intervention

Team factors3

  • Communication breakdown with other physicians
  • Communication breakdown with non-physician providers

Risk reduction reminders

The following risk management considerations have been identified for providing obstetrical care:

Antepartum

  • Ensure there is a reliable system in place to facilitate the timely receipt, effective review, and appropriate management and follow-up of antenatal tests.

Intrapartum (labour and delivery)

  • Communicate sufficient information to promote situational awareness about patient condition and progress.
  • Clearly communicate both the persistent fetal heart rate concerns and the clinical concerns to emphasize timely attendance of appropriate staff or delivery.
  • Have clear policies for the interpretation and management of atypical or abnormal fetal heart rate tracings.

Postpartum

  • Ensure that your documentation reflects your assessment of the patient’s postpartum condition and supports the diagnosis and the rationale for the treatment plan.
  • Provide clear postpartum instructions on assessment and monitoring.

Limitations

CMPA medico-legal cases represent a small proportion of patient safety incidents overall. Many factors influence a person’s decision to pursue a case or file a complaint, and these factors vary greatly by context. Thus, while medico-legal cases can be a rich source for important themes, they cannot be considered representative of patient safety incidents overall.

Now that you know your risk…

Mitigate your medico-legal risk with CMPA Learning resources.

Questions?

Please contact [email protected]




Notes

  1. There may be more than one complaint per case.
  2. Severe patient harm includes death, catastrophic injuries and major disabilities for either the mother or the newborn.
  3. Based on peer expert opinions. Peer experts refer to physicians who interpret and provide their opinion on clinical, scientific, or technical issues surrounding the care provided. They are typically of similar training and experience as the physicians whose care they are reviewing.