These strategies can help you reduce risks and keep your patients safe.
Review your tracking systems to ensure follow-up and patient notification for all test results in a timely manner, especially for mammograms, Pap smears, and prenatal genetic screening tests. Documentation must also reflect that all test results were reviewed by the provider and communicated to the patient. For paper records, the provider’s initials/date are the primary method of verifying review before the result is placed in the medical record. For test results received electronically, provider review and authentication within the electronic health record is acceptable. If results are considered to be borderline in any way, carefully explain the results to the patient and document the patient notification. Consider using written materials to augment your test result discussion with the patient.
Ensure that your test tracking system includes a mechanism for notifying the provider/staff when a result is not received. This notification should not be dependent on opening the patient’s record at a return appointment. Never tell patients to assume that “no news is good news.” Patients should expect to hear from you about the results of all tests.
Educational materials help raise patients’ awareness about issues that may affect their reproductive health. Keep in mind, however, that your patient population’s functional education level can affect quality of understanding and participation in healthcare regimens. Communicate using everyday language, and select educational literature that supports patients at all health literacy levels. Provide language services if necessary. Preview and recommend specific online educational videos, if applicable, as another way to inform your patients. Always encourage your patients to understand their medical issues, what actions they need to take, and why it is important for them to follow an individual health plan. For more information on health literacy, read our article “Challenges of Cultural Diversity in Healthcare: Protect Your Patients and Yourself.”
If information is deemed important enough to be included in the prenatal record template you use in your office, fill it in consistently. Leaving blank spaces on a prenatal record template may be interpreted as a breach of your own adopted standard. Document all important patient discussions in the prenatal record to ensure that the information is available to any obstetrical provider who might be covering labor and delivery when the patient presents for care.
Noncompliance in the Ob/Gyn Patient
Patients who do not follow recommended treatment plans are at greater risk for poor outcomes.1 When a patient refuses to comply with recommended diagnostic studies or treatment, inform her about the risks of refusing. Document the noncompliance or refusal with the patient’s reasons, and include a notation that risks were explained to the patient. In critical or time-sensitive situations, a letter that outlines the risks the patient is taking may need to be sent by certified mail. (For more information on this topic, see our articles, “Informed Refusal” and “Nonadherent and Noncompliant Patients: Overcoming Barrers.”)
To reduce your liability exposure with noncompliant patients, consider ending the provider-patient relationship. Recognize, however, that you have a limited window of time to end the relationship when dealing with an obstetrical patient. If a patient is pregnant, ending the relationship can safely be accomplished during the first trimester if the pregnancy is uncomplicated and the patient is given adequate time to find another practitioner. During the second trimester, a relationship should be ended only when the patient is transferred to another obstetrical practitioner prior to the cessation of services. During the third trimester, a relationship should end only under extreme circumstances (such as illness of the practitioner, etc.) For more information on this topic, see our article “Terminating Patient Relationships.”
Labor and Delivery Discussions
Discuss labor and delivery issues with your patient during the third trimester, when your patient has time to make informed decisions about her care. Have detailed discussions during office visits about the use of oxytocin for augmentation, vacuum or forceps assistance, episiotomy, and the possibility of shoulder dystocia or C-section. During labor is not the ideal time to obtain fully informed consent. Patients who are well informed about the possible course of their own labor and delivery are less likely to misunderstand medical interventions and interpret them as errors in care.
Ask your patient to discuss her birth plan with you far in advance of her admission for delivery. In the event a patient might deliver while you are not available, clearly communicate your patients’ wishes to the covering provider(s) before signing out. If you know that one of your partners does not agree with any portion of your patient’s birth plan (for example, using a birthing tub or rejecting fetal monitoring), communicate that information to your patient early in the pregnancy. This will give her an opportunity to meet with your partner to resolve any issues or to choose another practice.
Preparing for Emergency Situations
At your practice facility, encourage OB simulation drills that focus on response times, staffing, and resources being readily available for emergency situations. Drills do not have to utilize high-level simulation technology if it is not available, but they should include both staff and obstetrical providers in order to practice optimum teamwork coordination.2 Even if the hospital does not organize its own formal, interdisciplinary simulation drill training, an obstetrical provider can take the time on the labor unit to run a quick drill with available staff. Drills should not be conducted as a test of staff knowledge but should, instead, be an opportunity to practice. Repeatedly choreographing emergent events makes everyone more comfortable with the process when an actual event occurs.