[Rohan]

http://www.medpagetoday.com/OBGYN/Pregnancy/tb1/1559

BOSTON, Aug. 17-In an extraordinary public apology, Beth Israel Deaconess Medical Center here, a Harvard teaching hospital renowned for its obstetric care, revealed with remarkable candor its series of blunders that led to a tragic event one night not long ago.


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[RaeT,RN]

Thanks for sharing this article. A very sad outcome. I am intrigued by the FHR pattern. Our CNS says that most sentinel evens can be traced back to one critical decision. I wonder what that decision was in that case?

Our department has actually implemented "VHA training" based on this very principle - that airlines showed research that better teams produce better outcomes in terms of safety. It's interesting for me to make this connection. For the most part, we do have incredible teamwork on our unit. The thing that I like best about the VHA training is that they have required physicians to attend the classes as well. I have even heard one physician from a different group offer to do a delivery for another when she said she may not make it out of the OR in time. I was very impressed with that.

[Rohan]

Sorry about printing the whole article.

[daisybaby]

Quite an interesting article. I too wonder what that 'critical decision' would have been.

[USA987]

Very interesting information. Thanks for sharing.

[sewnina]

What are the protocols in other facilities regarding IV access, discharge home, fetal monitoring with the use of misoprostil?

[SmilingBluEyes]

You need to be more specific, in asking. Our policies vary regarding IV access and discharging.

Regarding cytotec, we have a policy that makes it mandatory to monitor the baby and uterine activity for 2 hours after placing the medication. If stable, mom may come off the monitor and ambulate/shower, etc as she choses until the next dose is due.

[RNnL&D]

Originally Posted by sewnina

What are the protocols in other facilities regarding IV access, discharge home, fetal monitoring with the use of misoprostil?

If you notice, this case occured in 2000. Since then, I believe there have been more stringent protocols developed for the use of Cytotec.

I don't know of any facility, in this area at least, that sends pts home on Cytotec.

[SmilingBluEyes]

Once cytotec'd they are "ours" for the duration. Unless the cytotec fails entirely, and they are considered NOT in labor and stable, with reassuring FHT, they do not go home. They are committed til the end, 99% of the time. And yes, we do see a lot of csections.

[wannabeL&D73]

How terribly heartbreaking.