abor and delivery (L&D) should be one of the most rewarding places for an anesthesiologist to work. The opportunity to assist people in the miracle of birth — occasionally helping to save a young life and frequently receiving profound thanks — what’s not to like? Yet concerns about safety and legal liability may temper our enthusiasm for L&D work. Our organization (Kaiser Permanente, a large nonprofit HMO) has been actively improving safety and reliability in L&D for the past four years with some remarkable improvements in safety climate, teamwork, job satisfaction and outcomes.^1-3 How do we build reliability in L&D?

1. Unique issues: Hospital units must accomplish two types of tasks to be reliable: a) predictably and efficiently carrying out routine and scheduled tasks, and b) managing the unexpected. Even more than the operating room, L&D units must be expert at rescuing patients when plans do not go accordingly. Several things help to guide this effort. First, a limited number of problems cause most (>80 percent) preventable birth injuries: recognition and response to a nonreassuring fetal heart rate (FHR), timely cesarean section when indicated, reliable and rapid infant resuscitation, instrumental delivery, shoulder dystocia, and use of pitocin.⁴ While this list is short, managing these problems is complex and requires a team. Failure to rescue may explain why >70 percent of the Joint Commission perinatal sentinel events involve communication as the primary failure⁵ and why many birth injuries occur to low-risk patients.

Another fact of life in L&D is error. Night shifts, changing patient situations, unclear FHR data, changes in workload, noise and stress — all of these factors are real. Errors will occur and must be identified and trapped early in their evolution. It is important to note that the L&D staff are usually very caring, skilled and hardworking. While there may be gaps in technical expertise, other factors are usually more important in failure to prevent patient harm. Some notable issues are systems that do not support reliable care (e.g., no prenatal charts, no team rounds), lack of communication training for providers, lack of team plans (FHR, emergencies, unit overload) and a culture that may value high-volume patient care and provider convenience over safety.

2. The team is the key: Teams are necessary to improve safety in most hospital units, including L&D.⁶ A unit safety council must own this process. This team should be multidisciplinary, should meet at least every two weeks and should get food. The unit council is charged to find and fix three systemic safety problems in the first year. Safety, however, is truly a team-based, frontline, shift-by-shift process. We begin with in-servicing every provider to the perinatal safety initiative — training in error, communications and the plans their unit has for change. These changes include daily, brief, multidisciplinary board rounds, preprocedural briefings and plans for unit overload management — the ability to stop and talk. A commitment we ask of our units: If a nurse calls for help at the bedside, the only acceptable response is to come, but we also ask that the problem and urgency be clearly stated.

3. Communication builds and supports these teams: Many other high-risk industries (aviation, military) have identified similar issues with poor communication causing harm. Programs such as “Crew Resource Management” have been quite effective at improving the reliability of communication, building teams and helping these teams to work effectively and trap errors.⁷ Some of the common themes in successful programs include:

a. Psychological safety: This means an environment of safety. It is OK to speak up if you see something going awry, even if you are not positive. If you are wrong, your concern will still be treated with respect. This goes hand in hand with accountability — you must speak up if you see a potential hazard.

b. Structured communication: Clarity matters, as does getting to the point. We have modified concepts from other high-risk industries to improve provider communication skills and to create times when they will happen. Briefings, assertion and “SBAR” briefings (situation, background, assessment, recommendation) can be taught and are well received by our providers. Key words and phrases include the use of callouts when things are OK and of clear ways to stop the line when things are not. L&D has unique barriers to this type of assertion — a nervous father with a camcorder can very effectively stop one team member from communicating a potential error or hazard! An agreed upon phrase — “stop the line, I need some clarity” — is very helpful to the team.⁸

4. Simulation is a powerful tool: We are using manikin-based simulation in our actual units to reinforce safety. Managing emergencies as a team is stressful but necessary. Simulation is a powerful tool that can uncover the system weaknesses that providers work around but which really should be fixed. Properly conducted simulation is very helpful in building the team culture, reinforcing communication skills and opening the door to regular team debriefing of actual events, even those that turn out well. Finally, medicine is the last high-risk industry that expects people to perform perfectly in complex, rare emergencies but does not support them with high-quality training and practice throughout their careers.⁹ Certain individual and team skills (crash cesarean, failed intubation, total spinal, shoulder dystocia, maternal cardiac arrest) require regular practice that cannot ethically occur in routine care. Teams that train for these emergencies and that are supported by tested systems are far more likely to succeed in the real rescue.

This is a very short summary of the creative work of many colleagues to improve safety — a road we are still traveling. We have found that we have excellent providers in our L&D units and that patient safety is a unifying theme that resonates with all disciplines. As anesthesiologists we have a critical part to play not only in providing safe anesthetic care but in helping to lead the efforts to build the L&D teams and units that will be truly reliable.

References:
1. McFerran S, Nunes J, Pucci D, Zuniga A. Perinatal patient safety project: A multicenter approach to improve performance reliability at Kaiser Permanente. J Perinat Neonatal Nurs. 2005; 19:37-45.
2. Sexton JB, Holzmueller CG, Pronovost PJ, et al. Variation in caregiver perceptions of teamwork climate in labor and delivery units. J Perinatol. 2006; 26:463-470.
3. McCarthy D, Blumenthal D. Stories from the sharp end: Case studies in safety improvement. Milbank Q. 2006; 84:165-200.
4. Knox GE, Simpson KR, Garite TJ. High reliability perinatal units: An approach to the prevention of patient injury and medical malpractice claims. J Healthc Risk Manag. 1999; 19:24-32.
5. Joint Commission on Accreditation of Healthcare Organizations. Sentinel Event Alert, July 21, 2004:30.
6. Uhlig PN, Brown J, Nason AK, Camelio A, Kendall E. John M. Eisenberg Patient Safety Awards. System innovation: Concord Hospital. Jt Comm J Qual Improv. 2002; 28:666-672.
7. Helmreich RL, Merritt AC. Culture at work in aviation and medicine: National, organizational and professional influences. Brookfield, VT: Ashgate Publishing; 1998.
8. Leonard M, et al. Achieving safe and reliable healthcare: Strategies and solutions. Chicago, IL: ACHE Management Series, Health Administration Press; 2004:37-64.
9. Aggarwal R, Darzi A. Technical skills training in the 21st century. N Engl J Med. 2006; 355:2695-2696.

Paul G. Preston, M.D., is a staff anesthesiologist, Kaiser-Permanente San Francisco Medical Center, San Francisco, California, and Physician Patient Safety Educator, the Permanente Medical Group, Oakland, California.