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Communication issues between nurses and doctors top the list of problems causing these sentinel/never events Contact Now

These medical mistakes should never happen during labor and delivery

Communication issues between nurses and doctors top the list of problems causing these sentinel/never events

As a former hospital administrator, I’m familiar with the accreditation requirement for hospitals from The Joint Commission. While the overall goal of accreditation is for hospitals to avoid errors and provide excellent patient care, another crucial requirement is that hospitals have policies and procedures in place to learn from their mistakes.

One of these quality improvement programs is called sentinel events. Sentinel events are outcomes that shouldn’t happen. Many doctors, nurses, and hospital leaders call them never events. Hospitals must report sentinel events to The Joint Commission, conduct an independent root cause analysis, and implement a process improvement plan to make sure the sentinel event doesn’t happen again.

In the practice areas of labor and delivery and newborn care, sentinel events are defined as any perinatal (around the time of birth)  death or major permanent loss of function unrelated to a congenital (genetic or inherited) condition in an infant having a birthweight of greater than 2500 g (5.1 pounds).

The Joint Commission released a study of all perinatal sentinel events that had been reported to it over a significant time span. The root causes identified by hospitals for these never events and tragic outcomes are interesting:

• 72% of the bad outcomes were caused by communication issues.

• 55% of the time, hospital organizational culture had a role. This includes things like hierarchy and intimidation, no teamwork, and failure to follow the chain of communication.

• 47% of the cases blamed staff incompetency.

• 40% of the time hospitals felt that they had not provided enough orientation and training to staff.

• 34% of the bad outcomes were caused by inadequate fetal monitoring.

• 30% of the cases had an issue where monitoring equipment or drugs weren’t available.

• 30% of the perinatal sentinel events were caused by poor hiring/credentialing and granting of privileges to physicians and midwives.

• 25% of the cases had staffing issues.

• 19% of the time there was a delay or unavailability of the doctor.

• 11% of the cases were complicated because prenatal information wasn’t available.

In my experience as a Houston, Texas medical malpractice lawyer, I know that hospital and physician defendants in birth injury cases often like to argue that the absence of early, consistent prenatal (pregnancy) care is the key issue. In Texas, the most recent data reflect that 62.5% of women receive prenatal care in the first trimester of pregnancy. Almost 99% of deliveries are in hospitals, with physicians delivering 95.3% of babies and a C-Section rate of around 35%.

Current data show that there are nearly 30,000 birth injuries each year in the United States, many of which could have been avoided with proper hospital, OB/GYN, and nursing care. The most common types include brain injury because of a lack of oxygen (hypoxia) during labor and delivery, cerebral palsy, spinal cord injuries, paralysis, brain bleeds (subdural or intracranial hemorrhaging), and others.

If your baby has a birth injury and you think the labor and delivery care may be the cause, then contact a top-rated experienced Houston, Texas medical malpractice lawyer for help in evaluating your potential case.

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him by calling 281-580-8800 or emailing him right now.


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