Interesting article

Published

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.

( Moderator Note: Terms of service prohibit reprinting articles in their entirety on this site. Please link the article, and only include a brief synopsis or paragraph from the article. Thank you for understanding).

Up Vote Up Vote ×

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.

Up Vote Up Vote ×

Sorry about printing the whole article.

Up Vote Up Vote ×

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

Up Vote Up Vote ×
Specializes in Behavioral Health.

Very interesting information. Thanks for sharing.

Up Vote Up Vote ×

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

Up Vote Up Vote ×
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

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.

Up Vote Up Vote ×
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.

Up Vote Up Vote ×
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

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.

Up Vote Up Vote ×

How terribly heartbreaking.

Up Vote Up Vote ×

I just relocated to a small hospital with a low census in central ny from a moderate size hospital in central ca and the difference in practice is mind boggling..at this little hospital they send pt's home after cytotec! (I really don't like cytotec, i much prefer cervidil,you can remove it!)I am completely uncomfortable with sending them home,been around too long and seen too many bad things...

Up Vote Up Vote ×
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Our hospital just revamped our cytotec policy and it's somewhat more restrictive and clear-cut, based on evidence and much study since it was first used to ripen cervices for labor. The beaut is all our doctors agreed on it immediately at the perinatal committee meeting, so at least they are all happy.

If anyone is interested, I can post the specifics here. I think it's a bit more work-intensive for nurses, but also think it is safer for our patients, too.

Up Vote Up Vote ×
+ Join the Discussion