The size of the labor wards: is bigger better when it comes to patient safety?

Abstract

Objective: To assess possible associations between the size of labor units and the frequency of approved obstetric claims.

Design: A nationwide retrospective descriptive study.

Setting: Denmark.

Population: All patients seeking financial compensation due to obstetric injuries occurring between 1995 and 2009.

Methods: In all, 1440 anonymized obstetrics claims were reviewed; 1326 were included in the study. Information regarding the annual number of deliveries for each place of injury was retrieved from the National Birth Registry.

Main outcome measures: Obstetric injuries approved by the Danish Patient Insurance Association categorized by labor unit size.

Results: The overall approval rate for submitted claims was 39.7%. Large labor units (3000-3999 deliveries/year) were found to have a lower approval rate (34.2%), compared with very large (≥4000 deliveries/year, 38.6%), intermediate (1000-2999 deliveries/year, 41.7%), and small (<1000 deliveries/year, 50.0%) units, (p < 0.05). The majority of compensation claims were approved with reference to the "specialist rule," assuming that if an experienced specialist had conducted the treatment differently the injury could have been avoided. Claims from small units showed a trend for being more often based on the specialist rule than seen in larger units (p < 0.05, test for trend).

Conclusion: The results may reflect that large labor units are living up to the principle of best practice to a greater degree. Several factors can be linked to the size of the labor unit and a better availability of in-house obstetricians as well as auxiliary specialists could be part of the explanation.

Keywords: Compensation; health facility size; insurance claim review; medical errors; obstetrics; patient safety.