Childbirth is a natural process that usually ends with a healthy mother and baby. But severe complications can occur suddenly that require a quick, accurate response. When things go wrong in obstetrics, the reasons are often unclear, but a lack of knowledge is frequently the root cause. Errors in clinical judgment were cited in 77% of more than 800 clinically coded obstetric malpractice cases according to CRICO Strategies, which offers clinical risk intelligence to 400+ hospitals and more than 180,000 physicians.

This study aims to show the hidden variation in the knowledge that may lead to errors during childbirth. It used the Amplifire learning platform, which is based in cognitive science and proven in over three billion learner interactions.

Study Design

310 Nurses and 192 Providers Patient-facing OB nurses and OB doctors at a large east coast hospital received four Amplifire courses covering critical aspects of obstetrics:

• Reduce incidents and near-misses associated with the health and safety of pregnant women and their unborn children

• Reduce the financial burden of malpractice claims associated with obstetrics

• Address the most frequently seen rule-based, skill-based, and knowledge-based active and latent errors in obstetrics

• Target and reduce the most common system errors related to electronic fetal monitoring (EFM) including fear of conflict, knowledge deficits, and communication failures

By the end of each course, 100% of the clinicians were proficient (confident and correct) on all the material

Electronic Fetal Monitoring

This heatmap is taken from Amplifire’s reporting dashboard and shows the clinicians sorted by their amounts of confidently held misinformation, uncertainty, and proficiency.

  • 654 clinicians generated 13,080 data points
  • 3,121 instances of confidently held misinformation were corrected
  • 2,672 instances of uncertainty were corrected
Electronic Fetal Heart Monitoring CHM Heatmap

Postpartum Hemorrhage

  • 654 clinicians generated 13,080 data points
  • 3,008 instances of confidently held misinformation were corrected
  • 1,962 instances of uncertainty were corrected
Post Partum Hemorrhage CHM Heatmap

Hypertension in Pregnancy

  • 194 physicians and 475 nurses generated 4,462 data points
  • 4,838 instances of confidently held misinformation were corrected
  • 3,529 instances of uncertainty were corrected
Hypertension in Pregnancy CHM Heatmap

Shoulder Dystocia

  • 184 physicians and 308 nurses generated 9,348 data points
  • 2,674 instances of confidently held misinformation were corrected
  • 3,122 instances of uncertainty were corrected
Shoulder Dystocia CHM Heatmap

Clinical Implications

Knowledge variation creates risk. Upon course completion, all of the clinicians had mastered the content 100%. Download the full case study to see all of the findings and clinical implications.

Obstetrics Case Study