litigation issue on midwives profession and carrier pathway

Litigation Issue on

Midwives Profession and

Carrier Pathway in Malaysia

ZAINI BINTI DAHIRAN

UNIVERSITY MALAYA MEDICAL

CENTRE

KUALA LUMPUR, MALAYSIA.

23 JANUARY 2016

Learning Outcome

1. State the code of conduct for

midwives in Malaysia.

2. Define the litigation.

3. Explain the liability in clinical

practice.

4. Explain the importance to prevent

complications to mother and baby.

Vision

Nursing in Malaysia will be delivered

by capable, effective, competent,

skillful and highly knowledgeable

nurses who will be able to provide

safe and holistic nursing care.

Focus

Provision of effective, holistic care to

individuals, families and community

across the life span.

In Malaysia

Laws governing practice of Nursing and Health Care Practice:

Nurses Act 1950

Midwives Act 1966

Dangerous Drug Act 1952

Medical Act 1971

Prevention and Control of Infectious Disease Act 1988

Birth and Death Registration Act 1957

Human Tissue Act 1974

Occupational Safety and Health Act 1994 (OSHA)

Private Healthcare and Facility Act 1998

Midwives Act 1966

The Midwives Act 1966 establishes a

Midwifes Boards provides for the

registration of nurse-midwifes and

regulates the practice of midwifery in

the country.

MIDWIVES BOARD MALAYSIA

THE CODE OF PROFESSIONAL

CONDUCT AND PRACTICE OF A

MIDWIFE

Code of Conduct

1. The midwife shall maintain at all times the

highest standard of care and professional

conduct. She shall not leave a woman in labour

unattended, she shall pass over her duties to the

midwife covering for her, and must hand over the

management of mothers at risk to relief midwife

before leaving her operational area.

MIDWIVES BOARD MALAYSIA

THE CODE OF PROFESSIONAL

CONDUCT AND PRACTICE OF A

MIDWIFE CONT….

2. The midwife must not only be well

prepared to practice her art but must also

maintain and improve knowledge and skill

at a consistently high level

3. The midwife must recognize and respect the

uniqueness and dignity of each individual and respond

to their needs appropriately, irrespective of their ethnic

origin and religious

beliefs, social standing and the nature of their health

problems.

4. The midwife shall hold in confidence all personal

information entrusted to her and make disclosures only

with consent or when required by the order of a court.

MIDWIVES BOARD MALAYSIA

THE CODE OF PROFESSIONAL CONDUCT AND PRACTICE OF A

MIDWIFE CONT….

5. The midwife acknowledges the responsibilities and

recognizes the limitations of the professional functions.

She should not prescribe or perform any procedure

outside her scope of responsibilities without medical

orders except in emergencies and to report to the

medical practitioner at the earliest opportunities.

MIDWIVES BOARD MALAYSIA

THE CODE OF PROFESSIONAL

CONDUCT AND PRACTICE OF A

MIDWIFE CONT….

6. The midwife works in a collaborative and co-operative

manner with health care professionals and others

involved in providing care. Any incompetence or

unethical conduct of her associates should be exposed

but only to the proper authority

7. The midwife should not abuse her privileged

relationship with mothers and the privileged access

allowed to her

MIDWIVES BOARD MALAYSIA

THE CODE OF PROFESSIONAL

CONDUCT AND PRACTICE OF A

MIDWIFE CONT….

8. The midwife is entitled to an appropriate

remuneration.

9. The midwife should not permit her name to be used

in connection with the advertisement of commercial

products or with any other forms of self-advertisement

10. The midwife’s behavior and conduct should conform

and adhere to standards of personal and professional

ethics which should not discredit upon the profession.

MIDWIVES BOARD MALAYSIA

THE CODE OF PROFESSIONAL

CONDUCT AND PRACTICE OF A

MIDWIFE CONT….

Litigation

Litigation arising from clinical negligence,

whist representing only the tip of the

iceberg of claims, complaints, incidents

and mistakes which do not result in harm,

nevertheless provides a valuable

retrospective analysis on the anatomy of

error.

What is litigation?

The process of taking a case to a court

of law so that a judgment can be made

(Cambridge English

Dictionary)

What is litigation?

Litigation is the term used to describe

proceedings initiated between two

opposing parties to enforce or defend a

legal right.

Litigation is typically settled by

agreement between the parties, but may

also be heard and decided by a jury or

judge in court.

NHS Litigation Authority

Nurses’ Liability

Liability means legal responsibility : a

nurse is legally responsible for actions

that fail to meet the standard of care

or for failing to act and thereby

causing harm.

Common causes of Liability

Nursing actions fells into following

categories

1. Treatment

2. Communication

3. Medication

4. Monitoring, observing, and

supervising.

Nursing Negligence Cases

Treatment

1. Enema to a preoperative patient with

appendicitis, which resulted in ruptured bowel

and appendicitis.

2. Improperly used equipment, resulting in air

embolism.

3. Failure to administer the correct oxygen level

4. Failure to attach a fetal monitor as ordered.

5. Burns to an infant from formula heated in a

microwave.

6. Failure to attend a patient having an asthma

attack, resulting in injuries such as brain

damage.

Communication

1. Failure to notify the physician of

changes in signs and symptoms

2. Failure to chart vital signs for hours in

a labor room.

3. Failure to advise the physician of

jaundice.

4. Failure to notify the physician of

circulatory compromise in a casted

leg

Nursing Negligence Cases

Medication

1. Wrong medication given on discharge

(topical eye anesthetic instead of

artificial tears)

2. Failure to give diazepam as ordered.

3. Improper administration of potassium

chloride.

Nursing Negligence Cases

Monitoring/ Observing/ Supervising

1. Failure to recognize dehydration and electrolyte imbalance.

2. Failure to monitor intravenous therapy

3. Failure to monitor fetal heart rate.

4. Negligent supervision of a psychiatric patient who attempted suicide

5. Negligent assignment and supervision of a student nurse who did not take blood pressure for 6 hours.

Nursing Negligence Cases

Liability in Obstetric Nursing

1. Failure to detect signs and symptoms of fetal distress

2. Failure to perform proper nursing functions when fetal distress is detected (e.g. turning patient on side, administering oxygen, calling the physician)

3. Failure to notify the physician in a timely manner of problems or deterioration of the patient’s condition.

Literature Review

In patient obstetric care results in more

50% of obstetric and gynecology claims

(White, Pichert, Bledsoe, Irwin, & Entman,

2005)

Literature Review

Fetal monitoring, neurologically impaired children, neonatal death, shoulder dystocia, uterine rupture, and ‘decision-to-incision’ time were identified as clinical factors frequently present in obstetric malpractice cases.

( American College of Obstetrician and Gynecologist , 2003).

Literature Review cont…

In a review of over 800 obstetric practice from the medical malpractice company owned by the Harvard medical community,

the average payment in obstetric-related malpractice claims was more than twice that of other clinical areas, with birth asphyxia, shoulder dystocia, intrauterine fetal death, and maternal hemorrhage accounting for the majority cases

(Crico Strategies, 2010)

Literature Review cont…

Angelini and Greenwald’s (2005) review

of 65 closed claims involving nurse –

midwives found assessment of fetal

monitoring and shoulder dystocia to be

the major sources of liability risk.

However, no knowledge of the

frequency, location, or experience of

midwives involved in litigation was

available.

Literature Review cont…

Contributing factors to the adverse

events were noted to be inappropriate

management of pregnancy, failure to

timely diagnose and treat “fetal distress”

and inappropriate management of the

second stage of labor via operative

vaginal birth

(Crico Strategies, 2010)

Literature Review cont…

Symon (200) conducted a survey of 1790

midwives and 211 physicians that aimed to

examine birth practitioners’ and perceptions

of the incidence of both malpractice litigation

and defensive clinical practice. The survey

found that a large majority of both midwives

and obstetricians believed that the frequency

of lawsuits has been increasing in recent

years, and that clinical practice was

becoming defensive.

Literature Review cont…

Midwives cited more detailed

documentation, earlier consultation, and

increased adherence to institutional as

examples of personal practice changes

resulting from fear of litigation.

Literature Review cont…Literature Review cont…

Being a defendant in a malpractice

lawsuit is known to be difficult and

stressful experience

(ACOG ,2005)

Literature Review cont…

Practitioners’ emotional responses to

litigation are multifarious and include

denial, anxiety, guilt, shame, and

isolation.

ACOG (2005) and Symon

(2005)

Literature Review cont…

COMMON AREAS OF LIABILITY AND

PATIENT HARM IN CLINICAL

PRACTICE

Common areas of liability and patient

harm in clinical practice

1. Fetal heart rate pattern interpretation, communication, and documentation

Common allegations

Failure to accurately assess maternal-fetal status

Failure to determine that the tracing being

recorded is of maternal rather than fetal origin

Failure to appreciate a deteriorating fetal condition

Failure to accurately communicate the maternal-

fetal status to the physician/nurse midwife.

2. Oxytocin for labor induction/augmentation

Common allegation

Initiation of oxytocin in the absence of evidence of fetal well-being

Failure to accurately assess maternal-fetal status during labor induction

Excessive doses of oxytocin resulting in uterine tachysystole, with or without an indeterminate or abnormal FHR pattern.

Common areas of liability and patient

harm in clinical practice cont…

3. Fundal pressure during the second stage of labor

Common allegations

Application of fundal pressure during second stage of labor that resulted in shoulder dystocia and/ or other maternal-fetal injuries

Application of fundal pressure during shoulder dystocia that further affected the shoulder and delayed the birth, resulting in maternal-fetal injuries.

Common areas of liability and patient

harm in clinical practice cont…

4. Shoulder dystocia

Common allegations

Failure to accurately predict risk of shoulder dystocia

Failure to diagnose labor abnormalities

Application of fundal pressure during shoulder dystocia, further affecting the shoulder and delaying birth, thereby resulting in maternal-fetal injuries

Common areas of liability and patient

harm in clinical practice cont…

5. Second-stage labor management

Common allegations

Failure to appreciate deteriorating fetal status

Failure to act on deteriorating fetal status by modifying maternal pushing efforts and initiating and usual intrauterine resuscitation measures

Injuries to the perineum that resulted in perineal lacerations, loss of pelvic floor integrity, and sexual dysfunction.

Common areas of liability and patient

harm in clinical practice cont…

6. Neonatal resuscitation at birth

Common allegations

Failure to anticipate resuscitation needs

of a baby whose mother experienced

pregnancy complications and/or after an

indeterminate or abnormal FHR pattern

during labor

Failure to have appropriate personnel

and equipment available for neonatal

resuscitation.

Common areas of liability and patient

harm in clinical practice cont…

PREVENTING LAWSUITS

Preventing Lawsuits

1. Effective communication

SBAR (situation, background,

assessment, recommendation) which

provides a framework for

communicating information that requires

a clinician’s immediate attention and

action in a specific, structured format.

2. Medical record

Charting in medical record, whether it

is still paper or, an electronic health

record is the best way to display the

care provided.

Preventing Lawsuits cont…

3. Rapport with clients

Establishing a rapport with the client

through honest, open communication

goes a long in avoid lawsuits.

Preventing Lawsuits cont…

4. Current Nursing Skills

Keeping one’s nursing knowledge and

skills current is vital to preventing errors

that may lead to lawsuits.

Taking advantage of in-service training,

workshops, and continuing nursing

education classes is an important part

of maintaining the nurse’s skill level.

Preventing Lawsuits cont…

5. Knowledge of the client

Recognizing the client who is lawsuit

prone can help reduce the risk for

litigation.

Common characteristics of this type of

client include constant dissatisfaction

with the care given, constant complaints

about all aspects of care, and negative

comments about other nurses.

Preventing Lawsuits cont…

Conclusion

Nurses are governed by laws and

regulation to ensure safe practice

Nurses should have knowledge about

law and its implication in nursing

practice.