What the Anesthesiologist Should Know before the Operative Procedure

The importance of patient safety

Medical error and preventable complications in hospitalized patients are the leading causes of accidental death in the United States. Hundreds of thousands of patients are injured or die each year due to preventable medical harm. The Institute of Medicine brought this epidemic to light in 1999 with their groundbreaking publication, “To Err Is Human.” This report suggested that up to 98,000 people die each year due to preventable medical errors. Sadly, little has changed in more than a decade since this report, and some evidence suggests that outcomes may be worse. Recent data by the United States Office of the Inspector General suggest that up to 14% of Medicare patients will be harmed during their hospitalization.

In response to the recognition that medicine has become increasingly complex and therefore potentially harmful, there has been a growing emphasis on ways to improve the safety of the care we provide, and to make the actions that we do in an effort to care for patients less likely to accidently cause them harm. Obstetricians, obstetric nurses, and obstetric anesthesiologists have been at the forefront of this patient safety movement.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

Evidence of harm in obstetrics

Maternal harm during obstetric care

The delivery of obstetric case has not been immune to the negative impact that the care we provide can have on maternal or neonatal outcomes. A growing body of evidence suggests that preventable harm is all too common on the labor and delivery suite.

Labor and delivery is the most common cause for hospitalization and cesarean delivery is the most common operation in the United States. Thus the exposure to potential medical error is high for the parturient and her fetus. Estimates of the number of women and babies that die or are harmed due to medical error during obstetric care do not exist to the same extent that they do for the general medical population. However, the evidence does suggest that the patient safety crisis is problematic in obstetrics and obstetric anesthesia. A recent review of the Nationwide Inpatient Sample found that approximately 1.3 per 1,000 hospitalizations for delivery was complicated by near-miss morbidity or mortality.
As many as 9% of deliveries are associated with a maternal or fetal complication. It has been estimated that up to 87% of perinatal adverse events are preventable, with poor teamwork, protocol violations, and unavailable staff being the common problems. Substandard care contributes to approximately 50% of maternal deaths, with poor communication and lack of teamwork being primary factors in the substandard care. Up to 72% of neonatal adverse events can be attributed to poor communication.
Among obstetric cases that go to litigation, poor communication and lack of teamwork is identifiable in 43%.

Additional evidence of substandard obstetric care

Even when there is no clear evidence of maternal or fetal harm, obstetric care may be substandard.

Up to 85% of women with preeclampsia receive substandard treatment for their blood pressure, a statistic that would likely improve with better teamwork and more involvement by an obstetric anesthesiologist.
Communication on the labor ward is often inadequate. One study found that obstetric nurses and obstetricians may communicate for only several minutes over the entire course of labor. Obstetric anesthesia handoffs are frequently short, interrupted by clinical care, and poorly structured.
Available evidence suggests that obstetric residents frequently communicate poorly or too late with senior obstetric staff or pediatric team members during obstetric emergencies.
Obstetric care providers often do not value patient safety initiatives.
In simulated environments, obstetricians repeatedly make the same mistakes when managing uncommon crises.
Finally, and perhaps most telling, many obstetric care providers do not grade their own institutions highly with regards to safety, and 30% would not want to be delivered in their own institution.

Substandard obstetric anesthesia care

Obstetric anesthesia care frequently contributes to poor care and adverse events.

Hemorrhage management: Both obstetricians and obstetric anesthesiologists grossly underestimate blood loss during obstetric hemorrhage. Partly due to this underestimation and partly due to poor standardization of care, poor management of maternal hemorrhage is a common cause of maternal morbidity and mortality. Data from the British Center for Maternal and Child Enquiries (Cemace, formerly CEMACH) suggest that inadequate intravenous access, delays in or inadequate appropriate transfusion, and inappropriate use of uterotonics by anesthesiologists contribute to adverse outcomes.
Maternal airway management: Failed intubation remains more common in obstetrics than in the general surgical population. While recent evidence suggest that death from failed intubation may be declining, obstetric anesthesiologists frequently mismanage the failed airway. Many have little experience with the “cannot intubate–cannot ventilate” parturient, and few regularly practice the skills needed to manage the airway or the teamwork skills needed in these crisis situations.
Preeclampsia: Several maternal deaths were reported in recent CEMACE data related to poor anesthetic management of the severely preeclamptic patient. As described above, inadequate blood pressure control by the obstetric team is common in this population. Profound increases in maternal blood pressure can occur during anesthesia management, especially during laryngoscopy. This hypertension, if left untreated, can lead to intracranial hemorrhage in the mother, placental abruption with fetal demise and obstetric hemorrhage, myocardial failure, and other consequences of malignant hypertension. Improper management of the maternal airway (all too common) combined with poor blood pressure control (also common) is a potentially lethal combination of errors
Cardiac arrest: Appropriate Advanced Cardiac Life Support (ACLS) in the pregnant patient requires several important modifications. These include:

Left uterine displacement during CPR
Cricoid pressure during mask ventilation
Early intubation to protect the airway
Slightly cephalad placement of the hands on the sternum during chest compressions
Delivery of the fetus within five minutes of the arrest if maternal circulation has not been restored

Based on data from simulated maternal cardiac arrests, ACLS is poorly managed by anesthesiologists.

Other causes of harm in obstetrics

Other, more systemic issues frequently contribute to substandard obstetric care and adverse maternal or neonatal outcomes. These include:

Lack of practice with rare or high acuity events.
Nonstandardized care. Practice variability due to lack of or outdated protocols can lead to confusion, error, miscommunication, and adverse events.
Latent system problems. A latent system error is a problem, or weakness, in the system of care that remains unnoticed until an acute event arises that requires the system to function in a specific way. The latent error then becomes apparent, contributing to an active error (and potentially to an adverse event). An example of a latent error might be the presence of two concentrations of magnesium sulfate on the labor ward. During the management of an eclamptic seizure, a nurse might choose the wrong concentration and then administer the wrong dose (an active medication error). This could lead to magnesium toxicity or failure to stop the seizure (followed by brain injury or aspiration of gastric contents). Data from simulations performed on labor and delivery units suggest that these types of latent error are very common and can lead directly to patient harm.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

Ways to improve patient safety in obstetrics

Patient safety in obstetrics can be improved in many ways. Several are described below.

General safety principles

There are many general safety principles that apply to the care of all patients. These include The Joint Commission national patient safety goals, a list of broad safety standards updated each year by The Joint Commission. All of these standards should be applied to the obstetric population. Examples relevant to the practice of obstetric anesthesia include:

Universal protocol: This is the process by which a patient and the surgical procedure are appropriately identified (using at least two unique identifiers), and the surgical site appropriately marked prior to any operative procedure. A final Time Out is then performed prior to incision to ensure that the surgery is performed on the correct body part. Because most procedures performed on labor and delivery suites are in the midline (cesarean delivery, D+C, cerclage placement or removal), marking of the surgical site is not usually needed as part of the Universal Protocol. Procedures on the ovary or other lateralized abdominal organs that might be performed at the same time as a cesarean section would require marking at the surgical site. Other components can be added to the final Time Out to ensure safe care, including the administration of prophylactic measures for the prevention of deep vein thrombosis (a significant problem in the obstetric population), the appropriate pre-operative administration of antibiotics to prevent surgical site infection, or the availability of extra personnel (pediatricians) or equipment (vacuum) that might be needed at the time of the operative procedure.

Avoidance of prohibited abbreviations: The use of look-alike abbreviations is an example of a latent error. For example, MSO4 written in an order sheet could mean morphine or magnesium sulfate. Clearly this could lead to confusion by the nursing staff who must administer the medication and potentially a medication error. Most medical centers have created lists of approved and prohibited abbreviations, and clinicians practicing in obstetrics should follow these regulations.

Medication labeling: The Joint Commission requires that any medication that is removed from its original container and not immediately administered by the provider who drew up the medication must be appropriately labeled. The label should include the name, strength, and amount of the medication, and the time that it will outdate. This currently applies to medications used during the administration of neuraxial anesthesia or analgesia. Sterile labels can be used to label spinal or epidural syringes.

Hand-offs: The transfer of care from one clinician to another has consistently been a high risk time for loss of crucial clinical information and error. This is especially important in obstetrics as each error could negatively impact two patients (mother and fetus), and because so much of the care provided is done in private, behind closed doors. Data indicate that hand-offs between obstetricians and obstetric anesthesiologists are frequently inadequate. Structured processes and templates can help to improve the quality of information transfer during hand-offs.

Clinical protocols

The use of clinical protocols is an effective way to decrease practice variability and thus improve patient care. From a teamwork standpoint, the use protocol helps to establish an expected plan and thus allows team members to anticipate next steps and to identify unsafe deviations from expected care.

Common obstetric protocols include management of maternal hemorrhage, use of oxytocin, management of induction of labor, thromboprophylaxis, monitoring during magnesium infusion, and documentation after adverse events.

Few obstetric anesthesia protocols exist, but the obstetric anesthesia provider should be aware of the obstetric protocols within the institution so they can be an effective member of the monitoring team.

6. What is the author's preferred method of anesthesia technique and why?

Improve communication

It is almost cliché to state that poor communication contributes to medical errors and adverse patient outcomes. What is generally less well understood, however, are the causes of poor communication or what can be done to improve communication in the clinical environment.

Understanding the causes

Communication failure occurs whenever the receiver understands the information in a way that is different from the intent of the sender. It is defined by the message that is received, irrespective of the message send. Thus, it is incumbent on both the sender and receiver to ensure proper information transfer. Communication failure can occur for many reasons. These include:

Interruptions: Perhaps as many of 30% of communication events in the perioperative period are interrupted.
Fear: Hierarchy and intimidation can negatively impact the willingness of subordinates to communicate, the quality of the communication when they do make an attempt, and the willingness to question a message when it is not completely understood.
Stress: This can included the stress from a heavy work load, the stress induced by a particularly difficult case (maternal hemorrhage), or even personal stresses not related to the work environment. Stress decreases how much we communicate, how effectively we send our message and how willing we are to professionally correct those who misinterpret our intent.
Overcommunication: Resource nurses may be bombarded with dozens or even hundreds of communication events each hour. Approximately one-third of communication events in the operating rooms are noncontributory to the care of the patient. This large number of communication events contributes to the interruptions as well.
Others: Noise, lack of an open communication culture, lack of structured communication style, or content can all contribute to communication failure.

Ensuring content

The quality of any communication depends, in part, on the significance of the information being transferred. Obstetricians and obstetric anesthesiologists can facilitate good communication by ensuring that several vital issues are always effectively communicated. These include:

Location: The nurses and obstetricians on the labor and delivery unit should always know the location of the covering obstetrician and anesthesiologist. They should know how to reach him/her, and who would cover in an emergency if the usual covering staff is unavailable for a period. The anesthesia staff should know where the obstetrician is and how to reach him/her. This is especially important in a private practice setting where the clinicians may have responsibilities in other clinical areas.

The clinical plan: While this may seem trite, it is crucial that other care providers know the specific plans before they are carried out. This can allow other providers to anticipate next steps and prepare appropriately, to identify unsafe deviations from the plans, and to identify if/when the plan itself may be unreasonable. Simple examples might be:

o An obstetrician may plan to allow a woman to push for 30 more minutes and then perform a cesarean delivery if the baby is not delivered. If a scheduled cesarean is planned for 60 minutes later, knowledge of the plan can allow the team to identify resources to perform both.

o An anesthesia plan to perform a spinal for a fourth cesarean section. The obstetrician might indicate that the last cesarean lasted 3 hours due to very dense adhesions. The plan might then change to a combined-spinal-epidural, and blood might be cross matched.

Concerns: Each specialty on a labor unit brings its own expertise to the care of the patient and thus each will likely identify different potential concerns. In a morbidly obese patient the nurse may be most concerned with the inability to adequately monitor the fetus. The obstetrician may worry about the risk of obstetric complications (gestational diabetes, fetal macrosomia, gestation hypertension) or the inability to perform an emergent cesarean delivery due to the body habitus. The anesthesiologist may be most concerned about the inability to place a regional anesthetic and the potential for a failed intubation. If the team shares these concerns among themselves and with the patient, a plan can be made to minimize the risk to mother and baby (perhaps early epidural and fetal scalp electrode in the case identified).

Facilitating communication

Communication of the content described may not occur without processes to support it. Several communication events can help ensure that this content is appropriately shared among the obstetric team.

Time Out: As describe above, the Time Out is an important (and regulated) part of patient safety communication. This communication moment can be used to state the plan for surgery, concerns (blood needed, etc.), or the location of additional resources (neonatologists) should they be needed.

Preprocedure Briefings: There is a growing body of literature in the general surgical population that multidisciplinary preoperative briefings decrease communication errors, improve clinical performance, and enhance the sense of team culture in the OR. While this is less well proven in obstetrics, briefings have been effectively used as part of larger patient safety initiatives on labor and delivery. On my unit we require a multidisciplinary briefing before every cesarean delivery. The entire team meets outside the holding area or patient room and discusses the plan. A template is used to ensure that all relevant topics are covered. These briefings help to ensure we all know and agree upon the plans, help us to change plans as needed (I have often changed my anesthesia plan based on information obtained at the briefing), and created a sense of team as we start the case.

Team Meetings: A multidisciplinary team meeting during which the entire labor board is reviewed is a good way to share plans and concerns. At my institution we have a meeting each shift to ensure that the plans of care are safe. Obstetricians have changed their plans after learning about issues related to other patients on the board.

Debriefings: A short debriefing after an operative procedure or even after a shift have help identify problems or concerns. Quality improvement efforts can be directed towards the issues identified.

Templates/checklists: Airline pilots routinely use pre-flight checklists to ensure that all important tasks have been completed. Anesthesiologists have used similar checklists to ensure that the machine has been appropriately checked and is operational. These lists are an acknowledgment of the fallibility of the human memory and have received considerable attention in the lay press by Gawande and others. Checklists can also be important in ensuring that all appropriate communication events and content have been completed.

Communication tools

Finally, several specific communication tools exist that can help ensure that the content of the message received is the same that intended by the sender:

Check back: The check back is most important communication tool. Most simply put, the check back is the process by which the receiver repeats the message back to the sender. The accuracy of message is then confirmed or corrected by the sender. The Joint Commission “Write it down and read it back” requirement for verbal orders is a form of check back. Senders should expect and demand that receivers repeat instructions to them.

Directed Communication: During a crisis it is common to need assistance, extra equipment or additional information. It is also common to be stressed. Simply calling out in a loud and stressed voice, “I can’t intubate, get me the airway cart” is often ineffective. Others may be busy and not hear the request, they may think someone else knows where the cart is and can do it faster, or they may simply not understand. By directing the request to an individual (“John, get me the airway cart. It is in the anesthesia work room.”), one allows the receiver to check back that they understand. They can then either complete the task or find someone who can.

SBAR: Many clinicians have now heard of the SBAR (Situation, Background, Assessment, Recommendation/Request). This tool facilitates structured communication and has been shown to improve the transfer of information during hand-offs. Any construct that help to ensure a standardized process and content for information transfer is likely to be effective.

2-challenge rule: The 2-challenge rule is the expectation that a concern about a clinical action is raised twice, usually with additional information the second time, to ensure that the receiving clinician has heard and understood the concern. For example, an anesthesia resident might ask, “Are you sure you want to give cefazolin before this cesarean section?” If the answer is, “Yes, that is the protocol,” the resident might respond, “But this patient has anaphylaxis to penicillin, should we give clindamycin instead?” Clinicians should praise those who advocate for safety when they respectfully challenge the care we provide to ensure that it is appropriate.

a. Neurologic

Team training

Medical team training has its roots in the concepts of Crew Resource Management (CRM). Originally developed in military aviation and now adopted by all civilian airlines, CRM is a set of behaviors and communication techniques designed to improve the coordination of crew actions, flatten hierarchies, set standards for communication, define members’ roles, and effectively resolve conflicts. More broadly defined, medical teamwork training is any structure that attempts to solve the issues of communication, resource management, conflict and communication. Many specific behaviors have been described in CRM, but Salas identified five as the most important (Salas, 2005).

Leadership: “Ability to direct and coordinate the activities of other team members, assess team performance, assign tasks, develop team knowledge, skills, and abilities, motivate team members, plan and organize, and establish a positive atmosphere.” Effective leadership is identified by specific sets of actions:

Facilitate team problem solving.
Provide performance expectations and acceptable interaction patterns.
Synchronize and combine individual team member contributions.
Seek and evaluate information that affects team functioning.
Clarify team member roles.
Engage in preparatory meetings and feedback sessions with the team.

Mutual Performance Monitoring (Cross-monitoring or Situation monitoring: “The ability to develop common understandings of the team environment and apply appropriate task strategies to accurately monitor teammate performance.” Specific behaviors include:

Identifying mistakes and lapses in other team members’ actions.
Providing feedback regarding team member actions to facilitate self-correction.

Back-up Behaviors (Mutual Support): “Ability to anticipate other team members’ needs through accurate knowledge about their responsibilities. This includes the ability to shift workload among members to achieve balance during high periods of workload or pressure.” Behaviors are:

Recognition by potential backup providers that there is a workload distribution problem in their team.
Shifting of work responsibilities to underutilized team members.
Completion of the whole task or parts of tasks by other team members.

Adaptability: “Ability to adjust strategies based on information gathered from the environment through the use of backup behavior and reallocation of intrateam resources. Altering a course of action or team repertoire in response to changing conditions (internal or external).” Actions are:

Identify cues that a change has occurred, assign meaning to that change, and develop a new plan to deal with the changes.
Identify opportunities for improvement and innovation for habitual or routine practices.
Remain vigilant to changes in the internal and external environment of the team.

Team Orientation: “Propensity to take other’s behavior into account during group interaction and the belief in the importance of team goal’s over individual members’ goals.” Behaviors are:

Taking into account alternative solutions provided by teammates and appraising that input to determine what is most correct.
Increased task involvement, information sharing, strategizing, and participatory goal setting.

The teamwork behaviors delineated by Salas run counter to traditional medical practice, and thus require staff education and a structured implementation strategy. The best ways to teach teamwork has not been established, but include written material, didactic sessions, simulation, cases study and vignettes, and practice and feedback in the clinical environment.

b. If the patient is intubated, are there any special criteria for extubation?

Simulation

The use of simulation to improve patient safety has grown tremendously over the past two decades. As with team training, simulation has its roots in aviation. First described in the 1960s ACLS with resuscitation mannequins, Gaba and Cooper modernized simulation in the early 1990s with the Anesthesia Crisis Resource Management (ACRM, a clear adaptation from aviation’s CRM). Currently simulation is used in three ways to improve patient safety in obstetrics.

Skills training

Simulation has been used by both obstetricians and obstetric anesthesiologists to improve technical skills. Skills assessment after the simulated skills training is generally done in the simulated environment. Thus, it is not clear that the improvements made in the simulator actually translate to improved skills in the clinical environment. To date, only one study has demonstrated that simulation training by obstetric providers is associated with improvements in clinical outcomes. No study has thus far demonstrated that simulation training by obstetric anesthesiologists is associated with improved performance or patient outcomes.

Simulation has been used to improve obstetricians’ skills in multiple areas, including management of eclampsia, maternal hemorrhage, shoulder dystocia, breech extraction, and adult and neonatal resuscitation. The simulated environment has also been used to identify deficiencies in care by obstetric providers that can then be the focus of future education.

Obstetric anesthesiologists have similarly used simulation to teach a wide range of clinical skills.

Blood loss: Clinicians routinely underestimate the degree of blood loss during maternal hemorrhage by up to 60%. This error rate increases as the actual blood loss decreases. A 60% underestimation of a 5-L blood loss is a life-threatening error. The use of both live and Web-based simulations has been shown to nearly eliminate this underestimation. Whether this improved performance in the simulator leads to better patient care and outcomes is yet to be tested. In addition, it appears that the improvements in blood loss estimation are largely lost within 9 months of training. How to make the improvement learned in simulation durable and transferable to the clinical environment are areas for suture research.

Airway Management: Anesthesiologists frequently do not follow the appropriate steps during failed intubation drills in obstetrics. Practice in the simulator improves adherence to the algorithms.

Epidural Placement: Several epidural simulators have been developed, ranging in complexity from highly integrated computerized models to water balloons and bananas. These may help novices to learn epidural placement more rapidly.

ACLS: Deficiencies in ACLS performance in the simulated parturient have been identified with simulation.

Management of Cesarean Delivery: Simulation training with an objective scoring system has been shown to improve resident learning in the management of a cesarean delivery.

In situ simulation

Recently, there has been a growing emphasis on the use of simulation within the clinical environment (in situ). A mannequin or actress portrays a patient on the unit where clinicians practice. Common drills in obstetrics include maternal hemorrhage, eclampsia, failed intubation, cardiac arrest, and shoulder dystocia. Obstetric anesthesia staff play a major role in several of these scenarios. The advantages of in situ simulation include: the ability to train the entire staff simultaneously, the ability to identify weaknesses within the system that are potential hazards to safe care, the ability to include other areas within the hospital in the drill (e.g. laboratories, blood bank, code teams), and the ability to train without leaving ones clinical environment. In situ simulation should either be directed at identifying and correcting latent errors on the unit, or at getting group practice at managing rare events.

Multiple resources are available to assist in the development of in situ simulations. The California Maternal Quality Care Collaborative (www.cmqcc.org/) has published references and scenarios for the simulation of maternal hemorrhage. Others have published very specific instructions for obstetric scenarios for high spinal and fire in the operating room. The Society for Simulation in Healthcare (http://www.ssih.org/Home), simulation centers (http://www.harvardmedsim.org, http://med.stanford.edu/VAsimulator/links.htm), the Agency for Healthcare Research and Quality (http://www.ahrq.gov) and others offer references and other simulation resources.

Starting with small simulations can be an effective way to initiate in situ drills. An example might be to test how quickly the team could initiate a cesarean delivery during a maternal code. A mock code can be called in a labor room using a standard resuscitation mannequin. The time it takes to get a scalpel to the surgeon could then be assessed. This simulation requires little special equipment (only the mannequin and an open labor room), is brief (scalpel should be present within 3-5 minutes), and addresses a specific issue. Similar drills assessing the ability to move a parturient to the operating room for a simulated emergency cesarean delivery, or getting advanced airway equipment to the anesthesia provider during a mock failed intubation, are other potential small drills. These drills should be directed at answering specific questions (e.g. How long until the baby is delivered in a maternal cardiac arrest? How quickly can an anti-seizure medication be administered in eclampsia?). Issues that cause delays or prevent effective care can be identified based on the answer to the question being asked. Once the unit is comfortable with these small simulations, larger scenarios (e.g. management of maternal hemorrhage, eclampsia drills) can be designed.

Teamwork training

Teamwork training is a subset of skills training, with a focus on non-technical skills. Simulation can be an effective way to teach teamwork and CRM concepts. A large body of literature demonstrates that clinicians enjoy this type of training and believe that it improves their ability to act like a team. Teamwork skills tend to improve within the simulated environment. However, no data yet demonstrate that simulation-base teamwork training as a sole intervention improves teamwork behaviors or patient outcomes in the clinical environment.

c. Postoperative management

What the individual can do

By definition, a single obstetric anesthesia provider can not have good teamwork. One needs a team to do that. Similarly, an individual can not approve protocols, run simulation drills or ensure effective closed-loop communication. However, there are many patient-safety activities that an individual can perform.

Advocate for safety activities. The individual clinician can ask leadership to establish protocols, initiate simulation and team training and encourage other safety activities. This might require working on the appropriate committees or approaching the departmental chairman. A strong local champion is the most effective way to get these safety initiatives adopted.

Communicate effectively: The communication tools described above do not require a team. Individuals can routinely use check backs and ask others to check back to them. By always communicating critical content (plans, locations, contact information, emergency coverage), the patient is made safer and an atmosphere of open communication is created.

Foster an atmosphere conducive to patient safety. Some physicians undermine the atmosphere of trust with disruptive or abusive behavior. A Joint Commission Alert indicated that “intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments.” This disruptive behavior is common on labor and delivery units. Conversely, clinicians who ask the team members to monitor their actions and to speak up when a concern is identified, who thank others for speaking up about safety concerns (even if the challenger is wrong), and who take the time to create communication moments (pre-op briefing) help to generate an atmosphere that is patient and safety centered.

Practice teamwork behaviors whenever possible. Monitoring the clinical plans of others and advocating for safety or helping a colleague when appropriate does not require formal teamwork training.

Ensure self care: Fatigue and burnout are associated with increased rates of complications (increased rates of complications are also associated with higher rates of burnout). Clinicians should be aware of the signs of fatigue and the common emotional impact that negative patient outcomes can have on clinicians.

Common signs and symptoms of sleep deprivation include irritability, sleepiness, socially inappropriate behavior, high stress level, memory loss, poor concentration, changes in appetite.

The impact that adverse events play on the well-being of the clinician and on his/her subsequent care has beginning to be understood. Common physical symptoms after a major adverse event include sleep disturbance, difficulty concentrating, eating disturbance, headache, fatigue, diarrhea, nausea or vomiting, rapid heart rate, rapid breathing, muscle tension. Physical symptoms include isolation, frustration, fear, grief and remorse, uncomfortable returning to work, anger and irritability, depression, extreme sadness, self-doubt, flashbacks

Clinicians should care for themselves (or find others to care for them) in the wake of a serious adverse event. Ways to help deal with and recover from this stress include:

Physical exercise, relaxation techniques (rest, meditation, massage).

Remind yourself that it is OK that you are experiencing expected reactions to a stressful event..

Keep your life as routine as possible.

Avoid alcohol and drug use.

Give yourself permission to react; don’t try to hide your feelings.

Eat regularly. Minimize the use of sugar and caffeine.

Seek help or support from a counselor, clergy, social worker, peer or other person you trust.

What's the Evidence?

Grunebaum, A, Chervenak, F, Skupski, D. “Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events”. Am J Obstet Gynecol. vol. 204. 2011. pp. 97-105.

Draycott, T.. “Does training in obstetric emergencies improve neonatal outcome?”. BJOG. vol. 113. 2006. pp. 177-82.

Merien, AE. “Multidisciplinary team training in a simulation setting for acute obstetric emergencies: a systematic review”. Obstet Gynecol. vol. 115. 2010. pp. 1021-31.

Pettker, CM, Thung, SF, Raab, CA, Donohue, KP, Copel, JA, Lockwood, CJ, Funai, EF. “A comprehensive obstetrics patient safety program improves safety climate and culture”. Am J Obstet Gynecol. vol. 204. 2011. pp. 216.e1-6.

Scott, S.D.. “The natural history of recovery for the healthcare provider "second victim" after adverse patient events”. Qual Saf Health Care. vol. 18. 2009. pp. 325-30.

Pettker, CM. “Impact of a comprehensive patient safety strategy on obstetric adverse events”. Am J Obst Gynecol. vol. 200. 2009. pp. 492.e1-8.

Gosman, G. “Introduction of an obstetric-specific medical emergency team for obstetric crises: implementation and experience”. Am J Obstet Gynecol. vol. 198. 2008. pp. 367.e1-7.

Lipman, SS, Daniels, KI, Carvalho, B. “Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises.”. Am J Obstet Gynecol. vol. 203. 2010. pp. 179.e1-5.

Wachter, RM. “Patient safety at ten: unmistakable progress, troubling gaps”. Health Aff (Millwood). vol. 29. 2010. pp. 165-73.

Robertson, B, Schumacher, L, Gosman, G. “Simulation-based crisis team training for multidisciplinary obstetric providers”. Simul Health. vol. 4. 2009. pp. 77-83.

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