Public Health Law Map - Beta 5 - Medical and Public Health Law Site

intentionally made, incorrect decisions. System failures (more informally called
“slipping through the cracks”) occur when a patient receives, or fails to receive, needed
care due to inadvertence. Patients are at the greatest risk for system failures when they
have nonserious conditions that are routinely managed without ongoing evaluation.
System failures usually involve overlooking unexpected data. This might be ignoring
the third call back by the mother of a child with an infected throat, which should have
triggered a reevaluation of the patient’s treatment. This is not usually a problem
because most children with infected throats have no major problem. It is the child with
meningitis injured when the physician inadvertently continues routine treatment whose
injuries lead to litigation.
In obstetrics, common system failures include failing to diagnose existing systemic
diseases, failing to offer screening tests at the appropriate time, failing to act on
positive test results, and failing to respond quickly to threats to fetal or maternal health.
System failures pose the major risk in obstetric care because most pregnant women are
healthy and most pregnancies end in the birth of a healthy baby.
Since the medical component of prenatal care is a screening program, failures in the
prenatal care system are irrelevant to most women because they do not have any of the
conditions for which the screening is performed. As with the child with an infected
throat, the system failure harms only the patient who does not have the usual condition.
In obstetrics, the failure of the prenatal system does not matter for most women; it does
matter for a woman who has a medical condition that requires nonroutine treatment to
protect her health or the health of the baby.
To use the MSAFP example assume the physician has all abnormal laboratory reports
put on the front of the chart for review. The file clerk loses 2% of all laboratory
reports. Since the physician depends on abnormal results being flagged, no flag is
taken to be a normal result.
Assuming a rate of 1 neural tube defect per 500 births, the probability of a missed
diagnosis is .02 ⋅ .002, or 1 per 25,000 births. The odds are that this practice could go
on for years before resulting in an injury in any given physician’s practice. That injury
can be very expensive. A $1 million award would not be unusual in such a case.
Assume further that an average obstetrician delivers 50 babies a year. (This is a low
number for a full- time obstetrician but is used to include family practitioners who
deliver babies and physicians with substantial gynecology practices.) Then 25,000
births represent 500 obstetrician-years, for a risk of $2,000 per obstetrician-year.
From a management perspective, delivering routine obstetrical services is more like
flying an airliner than like treating an acute illness: small things matter, and mistakes
are infrequent but costly. As with flying the airliner, most of the things that matter are
not done by the person in charge. The pilot does not service the engines, and most
prenatal care is done by persons other than the supervising physician.
1. Zero-Defects Management
Zero-defects management is based on the premise that it is better to detect
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