A 38-year-old woman with fetal loss and hysterectomy.
Sachs BP. JAMA. 2005;294:833-840.
Part of a series in JAMA entitled
, this case study discusses the unfortunate events surrounding a 38-year-old woman’s presentation to a labor and delivery unit. The case details a seemingly routine full-term pregnancy that rapidly evolved into a course of complications, ultimately leading to a fetal death, a hysterectomy, and a prolonged hospital course. The discussion shares the experience through the eyes of the patient, her husband, and the primary obstetrician. Further exploration of the case identified several specific factors and broader systems issues that contributed to the events. The author shares how this particular institution responded with overarching changes, including a greater emphasis on teamwork, communication, and appropriate staffing of labor and delivery units to promote safety.
Communication and teamwork in patient care: how much can we learn from aviation?
Lyndon A. J Obset Gynol Neonatal Nurs. 2006;35:538-546.
Predictors of likelihood of speaking up about safety concerns in labour and delivery.
Lyndon A, Sexton JB, Simpson KR, Rosenstein A, Lee KA, Wachter RM. BMJ Qual Saf. 2012;21;791-799.
Improving patient safety with team coordination: challenges and strategies of implementation.
Harris KT, Treanor CM, Salisbury ML. J Obset Gynol Neonatal Nurs. 2006;35:557-566.
New practices reduce childbirth risks.
Landro L. Wall Street Journal. July 12, 2006:D1. [Reprinted on Post-gazette.com].
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