Quality of Care/Patient Safety

Physician compliance with obstetric clinical pathways may protect against malpractice litigation

Clinical pathways, recommended step-by-step procedures for diagnosing or treating a particular medical problem, can improve care quality. Reduced malpractice litigation is another reason physicians and institutions should buy into these "best practices," concludes a new study. The researchers found that noncompliance with an obstetric clinical pathway was over three times more common for deliveries with associated malpractice claims than deliveries without such claims (43 vs. 12 percent). Furthermore, in 79 percent of the claims involving noncompliance with the clinical pathway, the main allegation in the suit related directly to departure from the pathway.

Adherence to clinical pathways might protect clinicians and institutions against malpractice litigation, concludes David M. Studdert, L.L.B., Sc.D., of Harvard Medical School. In the study, which was supported in part by the Agency for Healthcare Research and Quality (HS11285), Dr. Studdert and colleagues identified 290 delivery-related malpractice claims and 262 control deliveries (no related claims) at three hospitals. They identified clinical pathways implemented in 1998 as the standard of care for vaginal and cesarean deliveries. A nurse-reviewer examined the medical records to identify intrapartum care that did not adhere to the pathway.

Overall, 72 percent of deliveries adhered to the clinical pathway. Noncompliance with the clinical pathway was associated with a nearly six-fold increase in the odds of a malpractice claim. More than one-third (36 percent) of all obstetric claims were the result of noncompliant care. Failure to monitor the fetus was the most common type of departure from the clinical pathway among both claims (31 percent) and controls (32 percent). The other leading departures among claims were failure to complete prenatal records, failure to perform cesarean delivery according to the pathway, and failure to treat and diagnose group B streptococcus (9 percent for each one).

See "Reduced medicolegal risk by compliance with obstetric clinical pathways: A case-control study," by Scott B. Ransom, D.O., M.P.H., Dr. Studdert, Mitchell P. Dombrowski, M.D., and others, in the April 2003 Obstetrics & Gynecology 101, pp. 751-755.

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