Childbirth presents a variety of risks, such as sequelae or death of mother and child. Quality care by healthcare professionals is necessary to minimize child birth associated risk. Diagnosis errors, delays, and poor communication are considered childbirth malpractice; patients usually take legal action in these cases. This study explored medical errors and their prevention, focusing on midwives. The study collected and analyzed cases of malpractice from 2019 to 2023 using the Pm SHELL model. In a legal database search for “medical case law” and “midwives” from April to September 2023 found 19 cases, three cases in which the midwife’s actions and circumstances were described were identified and selected. A “delay in reporting from the midwife to the doctor” was considered as a common factor in all three cases. In Case-1, the report was made; however, important information was missing. In Case-2, incorrect decisions were made due to inappropriate cardiotocogram (CTG) placement. In Case-3, the problem occurred at the time of reporting, wherein one of the two midwives interrupted the report to the doctor and said that “the care for the patient is finished, so no further advice is needed. Following which, the doctor did not check the patient. In Case-1, education and training is needed to improve the midwife’s judgment and their understanding of protocols as following them can reduce judgment errors. In Case-2, real-time monitoring with CTG by multiple healthcare providers is required to ensure a rapid response system. In Case-3, midwife–physician communication and collaboration should be standardized.

Authors:
Yumiko Yamazaki, Kawasaki City College of Nursing, Japan

About the Presenter(s)
Professor YUMIKO YAMAZAKI is a University Professor/Principal Lecturer at Kawasaki City College of Nursing in Japan

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