Reducing obstetric litigation through alterations in practice patterns.

OBJECTIVE To estimate the extent to which obstetric malpractice claims might be reduced by adherence to a limited number of specific practice patterns. METHODS We examined all 189 closed perinatal claims between 2000 and 2005 from a single, large, professional liability insurer. Each case was subjected to three separate analyses: 1) whether the adverse outcome was caused by substandard care, 2) what changes in practice likely would have avoided the adverse outcome, regardless of standard-of-care considerations, and 3) to what extent did substandard documentation lead to payment in cases in which there was no objective evidence of substandard care. RESULTS Seventy percent of claims involving obstetric practice (accounting for 79% of all costs) involved substandard care. Payments in 85% of cases involving non-vaginal birth after cesarean (VBAC) fetal monitoring, 16% of maternal injury cases, 80% of cases involving VBAC, and 54% of shoulder dystocia cases were avoidable had four specific practice and documentation patterns been followed. CONCLUSION Most money currently paid in conjunction with obstetric malpractice cases is a result of actual substandard care resulting in preventable injury. Well more than half of hospital litigation costs might be avoided if physician practice included: 1) delivery in a facility with 24-hour in-house obstetric coverage; 2) adherence to published high-risk medication protocols; 3) a more conservative approach to VBAC; and 4) use of a comprehensive, standardized procedure note in cases of shoulder dystocia. LEVEL OF EVIDENCE III.